Smoke, Fire and Fumes in Transport Aircraft, Part 2

Transcription

SMOKE, FIRE AND FUMES
IN TRANSPORT AIRCRAFT
PAST HISTORY, CURRENT RISKS AND RECOMMENDED MITIGATIONS
Part 2: Training
First Edition 2014
A Specialist Paper by the
Royal Aeronautical Society
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The Royal Aeronautical Society is the world’s only professional body dedicated to the entire
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The Honourable Company of Air Pilots
A Livery Company of the City of London, incorporated by
Royal Charter.
The Guild of Air Pilots and Air Navigators of the British Empire was formed in 1929 for
‘pilots who had obtained high professional status as holders of a ‘B’ Licence and Air
Navigator’s Certificate’ by many of the leading aviators of the day. With as Patron His
Royal Highness The Prince Philip, Duke of Edinburgh, KG KT and as Grand Master His
Royal Highness The Prince Andrew, Duke of York, KG GCVO, the Company is a charitable
organisation that is unique among City Livery Companies in having active regional
committees in Australia, Hong Kong and New Zealand and North America. The Company,
the largest of the Livery Companies by total membership, received its Royal Charter in 2014
and adopted the new title, granted by Her Majesty, of The Honourable Company of Air
Pilots.
Main objectives
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To establish and maintain the highest standards of air safety through the promotion of
good airmanship among air pilots and air navigators
To maintain a liaison with all authorities connected with licensing, training and
legislation affecting pilot or navigator whether private, professional, civil or military
To constitute a body of experienced airmen available for advice and consultation and to
facilitate the exchange of information
To strive to enhance the status of air pilots and air navigators
To assist air pilots and air navigators in need through a Benevolent Fund
The first concern of the Company is to sponsor and encourage action and activities designed
to ensure that aircraft wherever they may be, are piloted and navigated by highly competent,
self-reliant, dependable and respected people. The Company has therefore fostered the sound
educational and training of air pilots and air navigators, from the initial training of the young
pilot to the specialist training of the more mature. It rewards those who have reached the top
of their profession through long years of experience and accomplishment and those who, by
their outstanding achievement, have added to the lustre of their calling.
The majority of members are or have been professional licence holders, both military and
civil, but many are also private pilot licence holders. Members operate not only aircraft in
airlines and all the branches of Her Majesty’s armed forces but also in every area of general
aviation and sporting flying.
To join, please contact the Clerk:
The Honourable Company of Air Pilots, Cobham House, 9 Warwick Court, Gray’s Inn,
London WC1R 5DJ, UK.
T +44 (0)20 7404 4032. F +44 (0)20 7404 4035. E [email protected] W www.airpilots.org
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SMOKE, FIRE AND FUMES
IN TRANSPORT AIRCRAFT
PAST HISTORY, CURRENT RISKS AND RECOMMENDED MITIGATIONS
Part 2: Training
A Specialist Paper prepared by the Flight
Operations Group of the Royal
Aeronautical Society
First Edition 2014
MAJOR CONTRIBUTORS
Dr. J. C. Barnett
Capt. H. M. Burton FRAeS
Mr. N. J. Butcher
Capt. J. M. Cox FRAeS
Capt. R. M. H. Weeks FRAeS
OTHER CONTRIBUTORS
Capt. T. Brandt
Dr. B. K. Burian FRAeS
Capt. J. H. Ransom
Capt. P. D. J. Terry FRAeS
Air Cdre D. L. Whittingham FRAeS
February 2014
ROYAL AERONAUTICAL SOCIETY
No.4 Hamilton Place
London W1J 7BQ
United Kingdom
Front Cover: Cabin Fire Training Facility. Dallas
Fort Worth Airport
T +44 (0)20 7670 4300
E [email protected]
This Paper represents the views of the Flight
Operations Group of the Royal Aeronautical
Society. It has not been discussed outside the
Learned Society Board and, as such, it does not
necessarily represent the views of the Society as a
whole, or any other Specialist Group or Committee.
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Royal Aeronautical Society copyright.
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SAFITA Part 2: Training
Preface
This document is Part 2 of the Royal Aeronautical Society’s specialist document ‘Smoke,
Fire and Fumes in Transport Aircraft’ (SAFITA), first published in February 2007. Sadly,
since the initial publication there have been additional accidents and fatalities due to in-flight
fires; therefore, the Flight Operations Group of the Royal Aeronautical Society decided to
update the document and re-issued it as ‘SAFITA Part 1: Reference’ in March 2013. Part 1
has been updated to highlight remaining safety issues; in addition, new sections concerning
lithium batteries, composite materials and predictive technologies have been added, together
with recommendations to reflect the current risks.
Several recent accidents and incidents have identified issues with crew training as a
contributory factor. In addition, studies have shown that there is a need for further guidance
on acceptable means of compliance for current aircraft crew fire training requirements.
Therefore, the Flight Operations Group identified a significant need to provide additional
information and recommendations for flight crew and cabin crew training to handle in-flight
fires. The Group has published this document as ‘SAFITA Part 2: Training’ to address this
need.
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Table of Contents
Preface......................................................................................................................................vii
Table of Contents ...................................................................................................................... ix
1.
Introduction ........................................................................................................................ 1
2.
Abbreviations ..................................................................................................................... 3
3.
Background ........................................................................................................................ 4
4.
Training priorities .............................................................................................................. 6
5.
Crew fire-fighting procedures ............................................................................................ 6
6.
Communication and coordination ...................................................................................... 7
7.
Practical fire training.......................................................................................................... 9
8.
Flight crew-specific training considerations .................................................................... 12
9.
Maintaining the smoke barrier ......................................................................................... 14
10. Hidden fires ...................................................................................................................... 15
11. Location of crash axes and crowbars ............................................................................... 17
12. Electrical fires .................................................................................................................. 18
13. Lithium battery fires ........................................................................................................ 18
14. Combi aircraft operations ................................................................................................ 19
15. Fire training instructors .................................................................................................... 20
16. Third party training .......................................................................................................... 20
17. EASA cabin crew initial safety training requirements .................................................... 20
18. Actions taken by aviation safety agencies ....................................................................... 21
19. Recommendations ............................................................................................................ 23
19.1
General................................................................................................................... 23
19.2
Training Equipment ............................................................................................... 23
19.3
Fire Training Scenarios ......................................................................................... 24
19.4
Regulatory Improvements ..................................................................................... 25
20. References ........................................................................................................................ 27
Appendix 1 ......................................................................................................................App 1-1
The EASA Requirements for Cabin Crew Fire Training and Suggested Guidance Material
.....................................................................................................................................App 1-1
Appendix 2 ......................................................................................................................App 2-1
Actions taken by aviation safety agencies in respect of in-flight fire .........................App 2-1
Appendix 3 ......................................................................................................................App 3-1
ICAO - Dangerous Goods ...........................................................................................App 3-1
Appendix 4 ......................................................................................................................App 4-1
Case Studies ................................................................................................................App 4-1
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1.
Introduction
A study by the UK Civil Aviation Authority (UK CAA, 2002) found that the average time for
a hidden fire on-board an aircraft to become catastrophically uncontrollable was less than 20
minutes. Fire tests conducted by various regulatory authorities have shown that fires allowed
to spread into the aircraft’s overhead area may become uncontrollable in as few as 8-10
minutes (FAA, 2004).
According to the Federal Aviation Administration (FAA), in the event of an in-flight fire:
“...delaying the aircraft’s descent by only two minutes is likely to make the difference
between a successful landing and evacuation, and a complete loss of the aircraft and its
occupants.” (2004)
The need for urgent and appropriate action by the aircraft crew is therefore essential, but they
will only be able respond effectively if they have been adequately trained. Whilst SAFITA
Part 1 addressed the current risks and proposed mitigations for smoke and fire events in
commercial transport aircraft, the purpose of SAFITA Part 2 is to serve as a reference
document for regulators, operators and training organisations, on training best practices and
compliance with mandatory requirements.
The mandatory requirements, or minimum standards, issued by some National Aviation
Authorities (NAAs) are not very specific as to how operators may comply with the
requirements or how compliance will be verified. Most operators and training organisations
already provide aircraft crew fire training in full compliance with the applicable requirements
and many provide more than is required. However, in 2009 the UK CAA identified that there
was non-compliance with the then requirements of EU OPS by some operators.
Hidden fires have been identified as a significant hazard for commercial aircraft operations
(UK CAA, 2002; FAA, 2004). However, in many NAA training requirements there is still no
specific requirement for appropriate aircraft crew training to mitigate the risks of this hazard.
The NTSB found: “…that current training programs still do not adequately prepare
crewmembers to fight the type of hidden in-flight fires likely to occur on airplanes” (2002).
The resulting NTSB recommendation A-01-85 (2002) for amendments to aircraft crew fire
training requirements has not been fully actioned by all interested parties.
The proliferation of personal electronic devices (PEDs) and increased dependence of aircraft
on electrical systems, as cited in the SAFITA Part 1 has not resulted in changes to aircraft
crew fire training requirements by some NAAs (RAeS, 2013).
SAFITA Part 2 provides operators and training organisations with guidance on how, as a
minimum, to comply with regulatory requirements and provides references to relevant
advisory material which might assist in the provision of aircraft crew fire and smoke training.
Recommendations regarding aircraft crew fire and smoke training made by NAAs and other
safety related organisations are included in this document.
Both fatal and non-fatal case studies of in-flight fires are included in Appendix 4. They
provide a useful study in the training of in-flight fires and should be incorporated into aircraft
crew training, whenever relevant. Alternative case studies involving a specific aircraft type to
be operated should also be considered.
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Where appropriate, relevant extracts are included from the EASA requirements and UK CAA
publications, including UK CAA Flight Operations Department Communications
(FODCOM) and Safety Notices, as well as documents produced by other aviation safety
agencies, such as the UK Air Accident Investigation Branch (AAIB), the FAA and the
NTSB.
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2.
Abbreviations
AAIB
AC
AD
AOC
APU
ATC
CAA
CVR
CRM
DGP
EASA
ELT
EU OPS
FAA
FODCOM
FSF
GCAA
HMSO
ICAO
JAA
IFE
NAA
NPA
NTSB
OM
PBE
PED
RAeS
RFFS
SCCM
TCCA
TSB
UPS
UK Air Accident Investigation Branch
FAA Advisory Circular
Airworthiness Directive
Air Operators Certificate
Auxiliary Power Unit
Air Traffic Control
Civil Aviation Authority
Cockpit Voice Recorder
Crew Resource Management
ICAO Dangerous Goods Panel
European Aviation Safety Agency
Emergency Locator Transmitter
European Union Regulations for Commercial Transportation by
Aeroplane
Federal Aviation Administration
UK CAA Flight Operations Department
Flight Safety Foundation
General Civil Aviation Authority of the United Arab Emirates
Her Majesty’s Stationary Office
International Civil Aviation Organisation
Joint Aviation Authorities
In-flight Entertainment
National Aviation Authority
Notice of Proposed Amendment
US National Transportation Safety Board
Operations Manual
Protective Breathing Equipment
Portable Electronic Device
Royal Aeronautical Society
Rescue and Fire Fighting Services
Senior Cabin Crew Member
Transport Canada Civil Aviation
Canadian Transportation Safety Board
United Parcel Service
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3.
Background
In May 1985 a fire totally destroyed one large spectator seating area at a football stadium in
Bradford, England. The fire, although quite small to start with, spread rapidly along the
length of the seating area. It took less than four minutes for the entire spectator stand to be
engulfed in flames.
There were 56 fatalities. The cause of the fire was probably a match or cigarette being
dropped on debris which then ignited (HMSO, 1986).
Bradford City Football Stadium fire – May 1985
If a fire on the ground with the potential for several different means of escape can be so
devastating and result in so many fatalities, how challenging would it be for an aircraft crew
to manage a serious in-flight fire, potentially one of the most significant and catastrophic inflight emergency scenarios that they will encounter? Prompt assessments and actions by
flight crew and cabin crew will determine the outcome of the emergency. The FAA and UK
CAA studies demonstrated that failure to act immediately to a fire or smoke threat may lead
to fatal consequences. (FAA, 2004; UK CAA 2002)
If a fire occurs in any area of the aircraft accessible to the aircraft crew during flight, a crew
member will have to fight the fire whilst keeping the flight crew fully informed of what is
happening. The flight crew will have to make rapid assessments of the situation and a
decision regarding diversion to the nearest suitable aerodrome, or if flying over water, may,
as an absolute last option, have to decide whether to ditch the aircraft.
According to the FAA (2004), delaying the aircraft’s descent by only two minutes may make
the difference between a successful landing and evacuation and a loss of the aircraft and its
occupants.
Aircraft crew should locate the source of the smoke and/or fire as quickly as possible and
deal with it urgently in order to ensure that the fire situation does not become uncontrollable.
They should initiate fire-fighting action immediately.
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Cabin crew should be trained to communicate the essential information to the flight crew
regarding an in-flight fire, so that the flight crew can make well-informed decisions. This
should be reflected in specific procedures that are covered in both classroom and practical
training. These procedures should be included in the AOC holder’s Operations Manual
Operators should ensure that there is consistency between flight crew and cabin crew
procedures. Training should ensure that each group is familiar with the each other’s
procedures, preferably by accomplishing joint training.
In recent years initiatives have been undertaken by several NAAs and other aviation safety
organisations. These include:
•
•
•
•
NTSB Review and Recommendations on In-flight Fires (NTSB, 2002);
FAA Advisory Circular 120-80 – In-flight Fires (FAA, 2004);
UK CAA Safety Plan of 2011/2013 (UK CAA, 2011);
UK CAA Cabin Crew Fire Training Needs Analysis (UK CAA, 2009).
In Advisory Circular (AC) 120-80 – In-flight Fires (FAA, 2004), the FAA identified that the
time for the situation to become non-survivable was as little as seven minutes, and that only
in one third of hidden fire events would the aircraft reach an aerodrome before the fire
became uncontrollable. An example of this is the accident involving an Air Canada DC-9
which diverted to Cincinnati in June 1983 when a lavatory compartment fire became
uncontrollable (NTSB, 1986).
DC-9 accident – Cincinnati June 1983
The FAA AC addresses the problems of hidden fires, but this issue is not addressed or
mentioned in any EASA requirements or advisory material.
The speed and effectiveness of aircraft crew actions are vital to a successful outcome of an
in-flight fire event. Many aircraft crew are not aware that the time available to successfully
deal with an in-flight fire may be extremely limited. This issue should be stressed during
initial and recurrent aircraft crew training and case studies should be included to demonstrate
the importance of taking urgent action.
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4.
Training priorities
The priorities in aircraft crew training for smoke, fire and fumes events have come into sharp
focus as a result of the tragic examples mentioned in this document. Regulators, operators
and training providers should ensure that the training emphasises the priorities highlighted by
the Flight Safety Foundation (FSF) in their checklist template for responding to smoke, fire
and fumes events (2005). The main priorities are summarised, in order, as follows:
1) Protection – aircraft crew use the appropriate equipment and tools to protect
themselves so that they can maintain the ability to handle the situation; any delay
in the use of protective equipment can have adverse consequences (AAIB, 2005);
2) Conduct the appropriate checklist – aircraft crew must action the appropriate
checklist as soon as possible to deal with the source of the smoke/fire/fumes; any
delay in performing the correct checklist can rapidly affect the survivability of the
situation (UK CAA, 2002);
3) Be prepared for a rapid diversion or even an emergency landing if the incident is
not resolved quickly – it is imperative that aircraft crew understand the urgency of
landing as soon as possible if the source of the smoke/fire/fumes is not identified
and/or extinguished and the situation is deteriorating (UK CAA, 2002).
Adoption of the training recommendations in this document should significantly improve the
chances of surviving a smoke/fire/fumes event, if the priorities above are reinforced
throughout the training.
5.
Crew fire-fighting procedures
To ensure effective cooperation and similar levels of proficiency, flight and cabin crew
should train together. For fires located in the cabin, many operators of larger aircraft types
have specific procedures for a three person team to deal with an in-flight fire. Such
procedures typically specify the following responsibilities:
•
The Fire Fighter: The crew member who first discovers the fire immediately
fights the fire and calls for assistance of another cabin crew member;
•
The Communicator: Calls for further crew assistance, alerts the flight crew and
conducts other actions as specified in the Operations Manual;
•
The Coordinator: Obtains back-up fire-fighting equipment and conducts other
actions as specified in the Operations Manual.
There may need to be some flexibility in this approach, in that the crew member who first
arrives at the location of the fire may not necessarily be best placed to continue to be the
primary fire fighter. This crew member fights the fire with whatever means are immediately
available. If the volume of smoke or its toxicity is such that PBE needs to be used, then the
donning of PBE should be undertaken by another crew member, whilst the first fire-fighter
continues to deal with the situation in the interim. Once PBE has been donned and additional
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fire-fighting equipment is made available at the location of the fire, the role of the fire-fighter
may need to be transferred to the second crew member.
Operators should assess the effectiveness of their procedures in respect of the number of
cabin crew required to be carried, together with the cabin configuration, systems and
installations. This should include consideration of multi-deck aircraft, where applicable, as
well as the minimum number of required cabin crew and also any cabin crew rest
requirements.
For operations with fewer than three cabin crew members, some fire-fighting procedures
might need to be combined and in such cases the effectiveness of the fire-fighting procedures
should be given particular attention. This is especially important for single-cabin crew
operations where one cabin crew member will be responsible for a number of tasks, including
communication and coordination with the flight crew. If the flight crew workload permits, the
cabin crew may require assistance from one of the flight crew to manage both fighting the
fire and managing the passengers. This will only be possible where there is enough suitable
smoke protection equipment for both crew members.
Operators should also consider procedures for the cabin crew to assist the flight crew in
dealing with a fire in the flight crew compartment when necessary. These procedures need to
include the following factors:
•
•
•
Flight crew procedures for the initial request and maintaining communication
with the senior cabin crew member;
Procedures for crossing the smoke barrier;
Crew communication procedures while cabin crew are in the flight crew
compartment; these procedures should take account of workload and task
allocation.
On passenger aircraft with no cabin crew, the operator should include guidance in the
Operations Manual for flight crew in handling a cabin smoke/fire/fume event. The priorities
remain protection, appropriate checklist, consider diversion or immediate landing. With these
priorities in mind, if workload permits and suitable protective equipment is available, one of
the flight crew may conduct fire-fighting in the cabin.
Flight crew may be required to assess and/or fight fires in both the passenger cabin and/or
flight crew compartment. Therefore, both fire-fighting procedures and training should be
standardised for flight and cabin crew. It is recommended that training is conducted jointly
where possible.
6.
Communication and coordination
As with any in-flight emergency, an in-flight smoke/fire/fume event requires effective
communication and co-ordination between all aircraft crew members to achieve a safe
outcome. During an in-flight fire the aircraft crew need to act as a complete team. Aircraft
crew training should include specific training objectives that ensure the operator’s
communication procedures for various in-flight smoke/fire/fume events are practiced and
crew members are proficient. Communication procedures for aircraft crew following the
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detection of a fire anywhere within the aircraft structure should be clearly described in the
Operations Manual. Aircraft crew should be trained in following these communication
procedures through the use of realistic training scenarios. Cabin crew should be trained in
how to communicate the essential information to the flight crew regarding an in-flight fire in
a concise, consistent and clear manner. The operator’s Operations Manual should include the
vital communication requirements, including essential information required during the initial
alert from cabin crew to the flight crew and communication between the cabin crew
locations. Communication training should include coordination between cabin crew
locations, as well as coordination with the flight crew. Emphasis should be placed on the use
of the aircraft interphone in order to preserve the smoke barrier between the cabin and the
flight crew compartment.
On aircraft with a single cabin crew member, the operator should ensure that the
communication procedures provided in the Operations Manual match the realities of a
smoke/fire/fume event in the type of aircraft. Clear priorities should be established for the use
of protective equipment, alerting the flight crew, maintaining a smoke barrier as far as
possible, fire-fighting and passenger handling. The use of appropriate scenarios in training
should ensure that cabin crew practise and demonstrate their proficiency.
On passenger aircraft with no cabin crew, the operator should provide guidance in the
Operations Manual for the flight crew in communicating with and handling the passengers in
the event of a smoke/fire/fume event in the cabin. There may be no barrier between the cabin
and the flight crew compartment and the passengers may be faced with flight crew in full
protective equipment, where such equipment is not available to them. Training should ensure
that flight crew have practice in passenger handling during such a scenario, especially if they
are flying an aircraft that does not have a flight crew compartment door. The training should
include initial passenger briefing, passenger control and emergency briefings for
landing/ditching. Operators should use realistic scenarios in training that follow the full
sequence of events to an appropriate conclusion. Combined training with cabin crew and/or
the use of experienced cabin crew instructors can be very beneficial for flight crew that have
never been exposed to good cabin crew training.
The FAA issued Report Number DOT/FAA/FS-88/1 (Cardosi and Huntley, 1988), titled
‘Cockpit and Cabin Crew Coordination’. The FAA Report stated: “Cockpit and cabin crew
coordination is crucial not only in emergencies, but also during normal operations.”
Some twenty five years later, this statement is still valid, and even more so with the
installation of flight crew compartment security doors on larger aircraft that are locked during
flight. As a result, the primary means for communication between the flight crew and the
cabin crew is the interphone system, rather than face-to-face communication. In their report
the FAA considered that one of the problems of coordination was with cabin crew not
providing information to the flight crew in a timely manner.
In the intervening years, Crew Resource Management (CRM) has been expanded to include
all aircraft crew members including cabin crew.
As in any emergency, CRM is an essential element of aircraft crew procedures. All aircraft
crew should have access to accurate and concise information as the situation develops, this
includes updates from the cabin and suitable briefings from the flight crew, so that all crew
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members can plan and act in a coordinated manner. Crew should be aware of the stress and
workload on crew members, especially the flight crew and those fighting the fire.
Flight crew should be able to rely on accurate information received from the cabin crew
regarding an in-flight fire or smoke event. The information to be communicated by the cabin
crew to the flight crew and senior cabin member should include the following:
•
•
•
•
•
•
•
Which cabin crew member is speaking and from what location;
The location of the fire or smoke;
The source of the fire and any associated smell;
The size of the fire, the amount and colour of the smoke that is being produced;
The cabin crew actions being undertaken and the number of fire extinguishers
used;
Passenger reaction and cabin crew actions to control the situation;
The development of the situation, when the fire is extinguished, and the conduct
of post-fire procedures.
In some in-flight fire or smoke situations, it might be necessary for the cabin crew to
communicate with the flight crew whilst wearing PBE via the interphone; some PBE designs
make such communication difficult. UK CAA CAP 789 addresses such issues in respect of
practical training (2011). Such issues should be addressed in both initial and recurrent
practical fire training.
Communication issues related to the locked/secured flight crew compartment door should be
specifically addressed in flight crew and cabin crew procedures and training, as applicable to
the aircraft type to be operated. This will need to include possible scenarios where, due to
failure of the interphone system, it might be necessary for the flight crew compartment door
to be opened to allow face-to face communication between flight crew and cabin crew. In
these circumstances, procedures should ensure that the migration of smoke or fumes into the
flight crew compartment from the cabin is minimised and that the smoke barrier is
maintained.
In aircraft with no flight crew compartment door, aircraft crew training needs to emphasise
the importance of flight crew protection; any delay in the use of protective equipment could
have serious consequences (AAIB, 2005). Training should also address any possible
mitigating actions that could be taken, such as the use of a curtain or other suitable barrier
that will not adversely affect an evacuation. In addition, flight crew should be fully familiar
with the smoke removal procedures for their aircraft. Flight crew training should provide
guidance about how to evaluate whether smoke is the greater threat and whether flight crew
actions should shift to smoke removal procedures. Operators should consider whether such
procedures should be memory actions for aircraft without a smoke barrier.
7.
Practical fire training
As previously mentioned, the UK CAA identified that there was non-compliance with the
then requirements of EU OPS by some operators (2009). The Flight Operations Group of the
Royal Aeronautical Society identified a need for further guidance on acceptable means of
compliance for current aircraft crew fire training requirements. Comprehensive guidance is
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provided in Appendix 1. This section addresses the challenges faced by operators trying to
provide realistic practical aircraft crew fire training.
The Montreal Protocol on Substances that Deplete the Ozone Layer, last amended by the
nineteenth meeting of the parties in September 2007, is currently ratified by over 190
countries (UNEP, 2007). The Protocol bans the production of Halon and prohibits its
discharge during fire training. Aircraft crew cannot actually experience the discharge of
Halon on a live fire during practical training. Halon extinguishers filled with water as an
alternative extinguishing agent do not accurately replicate the extinguishing characteristics of
Halon or the techniques of application required for the agent. Some Halon replacement
extinguishing agents may provide better alternatives to water as a training medium.
Another issue is the amount of pressure required to activate a fire extinguisher. Some
extinguishers used in training do not exactly replicate the extinguishers carried on board
aircraft. This is especially true of the integral brass seal that needs to be broken on some types
of Halon extinguishers when the operating handle is pressed. The force needed to break the
seal on an ‘operational’ fire extinguisher is often significantly greater than the force needed to
activate the discharge of the fire extinguishers used in training. This important difference
should be addressed in training.
During training in the 1980’s, aircraft crew usually fought fairly large fires in the open air. At
that time oil tray fires were favoured and Halon could be used. These fires were usually quite
large and challenging. They could be difficult to extinguish unless the correct procedure was
used, such as aiming the extinguisher at the base of the flames. Re-ignition was often a major
factor. Whilst a fire of such size would be most unlikely to occur on a commercial aircraft, it
did provide an awareness of the problem and also the effectiveness of Halon.
Practical fire training in the 1980’s
Since such fires were not realistic to a cabin fire situation, in the late 1980’s the UK CAA
decided that the requirement should be changed to cabin crew fighting a fire representative of
an interior aircraft fire. This has now become an EASA requirement in AMC1
ORO.CC.125(d) and ORO.CC.140.
Unfortunately, in some cases this has resulted in aircraft crew dealing with fires of such a
small size that extinguishing the fire provides little or no challenge and consequently offers
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limited training value. The size of the fire to be extinguished in practical training and the
level of difficulty in extinguishing the fire are critical to achieving verification of aircraft
crew proficiency. A fire that is easily extinguished in training may well lead to a false sense
of security and may not address the difficulties of dealing with an actual in-flight fire
including the issue of re-ignition or the correct means of operating a fire extinguisher.
The size of the fire and the level of difficulty in extinguishing the fire in practical training
should be consistent with real situations. The Operations Manual should specify the
following:
•
•
•
The actual size of the fire and the fire source(s) used in the training;
The level of difficulty required to extinguish the fire;
The different fire scenarios appropriate to the aircraft type to be operated.
Unfortunately, this is not always the case and the level of difficulty and assessment of aircraft
crew proficiency are often down to the subjective assessment of the individual instructor;
therefore, effective standardisation is required.
Training in the use of Protective Breathing Equipment (PBE) during practical training also
presents problems. The vast majority of aircraft crew will probably never remove PBE from
its container nor remove PBE from its sealed packaging other than during an actual in-flight
fire or smoke emergency. During training sessions PBE neck seals will be stretched and/or
damaged due to repeated use; this means that most aircraft crew will never don a PBE that
has a neck seal that fully replicates an operational unit.
The UK CAA in their Paper 2009/01 – Cabin Crew Fire Training – Training Needs Analysis
(2009), stated: “The only part of the procedure of using PBE that is practiced is the actual
donning of the PBE. This is usually conducted on training units that do not replicate the
tightness of the seals to be encountered on an operational unit. In one case the condition of
the PBE neck seals, were in such a bad state as to be almost non-existent.”
A training unit neck seal that is damaged does not offer comparable experience of donning a
live PBE with an unused neck seal which will be much more restrictive. Whilst it may be
difficult to replicate the donning of a live PBE unit in this respect, operators and training
organisations need to exercise quality control for PBE training unit neck seals so that the
training remains as meaningful as is practical.
Some operators and training organisations achieve the EASA requirements for aircraft crew
fire-fighting in separate training scenarios, with aircraft crew extinguishing a fire without the
use of PBE, and the use of PBE by aircraft crew when not extinguishing a fire. This would
appear to be meeting the mandatory requirements with little consideration as to the
probability of a serious in-flight fire or smoke event, when both fire extinguishers and PBE
will need to be used simultaneously, perhaps whilst using other equipment such as fire
gloves.
Combining fire extinguisher training with PBE training is certainly feasible since some
operators and training organisations achieve both elements in one practical fire training
scenario. Therefore, regulatory requirements should reflect the likelihood of an in-flight fire
in which different items of fire safety equipment need to be used simultaneously. Attempting
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to meet practical fire training requirements in unrealistic, separate fire training scenarios is
not satisfactory.
Combining fire extinguisher training with PBE training & fire gloves
Many operators and training organisations now use gas-powered fire training rigs, where the
actual fire is controlled by the instructor. In the case of some fire training rigs, it is the
instructor who actually turns off the gas supply, thereby extinguishing the fire, rather than the
individual aircraft crew member achieving this, which might not be in full compliance with
the EASA requirements. Additionally the EASA requirement in ORO.CC.115 paragraph (d)
states: “Checks shall be performed by personnel appropriately qualified to verify that the
cabin crew member has achieved and/or maintains the required level of proficiency.”
Therefore, the standards applied by the instructor should be consistent with the procedures
and should be specifically defined in the Operations Manual. Operators need to carefully
consider the limitations of fire training rigs in respect of instructor actions and the
standardisation of training provided to aircraft crew.
8.
Flight crew-specific training considerations
Flight crew training for smoke/fire/fume events normally occurs in two separate training
events. Flight crew procedures and diversion/emergency landing procedures are conducted
during flight simulator training; whilst fire-fighting and communication with the cabin crew
are dealt with during safety and emergency procedures training. Some operators have access
to ground training simulators that include a flight crew compartment where full, realistic
scenarios may be practised, but many do not. Flight crew fire training is often conducted at a
fire service training facility or in an unrepresentative cabin environment. This is especially
the case in business aviation, where there is a shortage of representative training facilities.
As recommended by most regulatory authorities, flight crew safety and emergency
procedures training should be combined with cabin crew training, where practical. Flight
crew may be required to fight a fire in the flight crew compartment, crew rest area and/or
assist in the cabin, so they should have the same level of proficiency as the cabin crew. As
already stated, combined training is also vital to ensure good communication and CRM
proficiency between flight and cabin crew. Flight crew operating aircraft without cabin crew
can also benefit from the expertise of an experienced cabin crew emergency procedures
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instructor, so that the flight crew are provided with suitable training in cabin fire-fighting
procedures and passenger handling considerations.
Flight crew training objectives should emphasise the priorities of the Flight Safety
Foundation template (FSF, June 2005); the first priority being protection. The training should
emphasise the importance of checking and maintaining good communication after donning
protective equipment.
The flight crew should then prioritise the appropriate checklist. FSF and the RAeS
recommend that operators use or develop an integrated smoke/fire/fumes checklist for
situations where the source of the smoke/fire/fumes is unclear (FSF 2005; RAeS 2013).
Flight crew training should emphasise the importance of tackling the source of the
smoke/fire/fumes as quickly as possible and the reasoning behind the integrated checklist, if
adopted. Flight crew should be familiar with the information that the cabin crew should
provide (RAeS, 2013).
If the source is not confirmed visually to be extinguished after the initial actions, the flight
crew should then immediately initiate a diversion to the nearest suitable airfield. Training
should emphasise the importance of keeping the senior cabin crew member briefed on the
flight crew plans, particularly time constraints and the nature of any emergency landing.
Flight crew should be aware that cabin crew may have urgent information concerning the
development of the situation in the cabin and they must balance the need to manage their
workload with the need for up to date information from the cabin. An out of date or incorrect
understanding of the cabin situation can have serious consequences (NTSB, 1986).
If subsequent action does not result in visual confirmation that the source has been
extinguished, then the flight crew should consider an immediate emergency landing or
ditching. Training should involve scenarios that continue to a logical conclusion and include
the requirement for further communication between the flight crew and the cabin crew.
For operations with only one cabin crew, flight crew training should involve scenarios that
include passenger handling and other situations where flight crew assistance may be required
by the cabin crew.
For operations without cabin crew, the priorities of the Flight Safety Foundation template still
apply (FSF, 2005). Operators should ensure that their training includes scenarios involving
the decision for one flight crew member to leave the flight crew compartment for fire-fighting
and/or passenger management. The training should include the procedures for transferring
from flight crew compartment protection equipment to portable protection equipment and
vice versa. The training should also include the communication procedures for rapid recall to
the flight crew compartment and considerations for aircraft not fitted with an interphone.
Operators should also include training in passenger handling for crowd control, passenger
assistance for smoke inhalation, and passenger emergency briefing.
Recent air carrier incidents and accidents have highlighted a lack of understanding among
some flight crews regarding the proper use of crew oxygen masks when faced with smoke or
fumes in the cockpit. The fatal accident involving the crew of United Parcel Service (UPS)
Flight 6 departing Dubai, UAE, for example, when faced with substantial cockpit smoke,
donned their oxygen masks at the appropriate time, yet one crewmember left his mask at the
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NORMAL setting, allowing smoke to enter his mask along with minimal amounts of oxygen.
On another cargo aircraft incident, the 3 flight crew, when faced with fumes in the flight crew
compartment, placed their masks in the EMERGENCY setting; this setting so impeded
communication that each flight crew member would pull his mask away from his face to
communicate both with ATC and within the cockpit.
Flight crew oxygen mask training historically has been limited to certain simulator events.
Often the masks – and smoke goggles, if installed – are allowed to be removed so as not to
impede training. Additionally, the flight simulator masks often do not actually replicate the
behaviour of the actual masks in the aircraft; e.g., using the mask in the simulator may allow
perfect communication at EMERGENCY flow settings, but when faced with using the same
setting in actual flight, communication may be very difficult.
Finally, some mask controls are not intuitive. It may be difficult for the user to identify the
mask setting once it has been donned. For that reason, oxygen mask training should be
sufficient and repetitive enough to ensure a high level of proficiency that flight crew can
maintain even in the stressful circumstances of a real emergency.
In addition to existing flight crew oxygen mask training, each operator should include the
following:






9.
Clear guidance regarding when it is appropriate to use each mask function (i.e.,
NORMAL, 100%, EMERGENCY);
An SOP requiring masks to be stowed with 100% selected, unless this generates a
constant flow of oxygen;
Actions to take if communication difficulty is encountered in the EMERGENCY
setting;
Guidance regarding communication while wearing masks (i.e., using the flight
interphone for intra-cockpit communication vs. using ATC Comm for all
communication);
Repetitive, hands-on drills with masks in a classroom or other non-simulator
environment to increase familiarity with controls;
Alternate cockpit sources of oxygen in the event of mask malfunction during use,
including locating that source in extremely low visibility.
Maintaining the smoke barrier
SAFITA Part 1 deals with the importance of the smoke barrier and this issue should also be
addressed in aircraft crew training (RAeS, 2013).
Minimising the migration of smoke from the cabin into the flight crew compartment is
essential for the continued safe operation of the aircraft.
In most large transport aircraft the flight crew compartment door is a major part of the smoke
barrier between the flight crew compartment and the passenger cabin. In the event of an inflight fire in the cabin, it is essential that the flight crew compartment door remains closed
and that the primary communication between the flight crew and the cabin crew is conducted
by means of the crew interphone system.
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In the event of a fire occurring in the flight crew compartment, the commander may decide
that the flight crew compartment door is opened and this may in any case be necessary if
cabin crew assistance is required to deal with the fire.
Aircraft crew procedures and associated training should address these issues during initial
training and recurrent training.
10. Hidden fires
Most in-flight fires are quickly detected and are dealt with rapidly and successfully by the
aircraft crew.
However, an in-flight fire that goes undetected for even a short time, has the potential to grow
in size and become uncontrollable, probably resulting in a catastrophic event.
Fires that are “hidden” are not readily accessible, may be difficult to locate and are more
challenging to extinguish. Some examples of hidden fires would be fires behind sidewall
panelling or in overhead areas. Hidden fires present significant problems for aircraft crew, in
terms of identifying the exact source and location of the fire. This creates difficulties for the
effective discharge of extinguishing agents at the actual source of the fire.
For many years aviation safety agencies around the world have raised the issue of hidden
fires and the problems with aircraft crew dealing with such an in-flight event.
The Transport Safety Board of Canada (TSB) in their 2000 Interim Aviation Safety
Recommendations – In-flight fire-fighting – Swissair Flight 111 (MD11), stated:
“Where access is relatively easy, such as exposed galley areas, existing procedures and
training using hand-held fire extinguishers have proven to be adequate. However where the
source of smoke/fire is not obvious, or access to the area is difficult, the situation can become
hazardous very quickly. Areas that are not readily accessible have not been considered when
planning for in-flight fire fighting. Therefore, there has been little or no training provided for
aircraft crews on how to access areas behind electrical or other panels, attic areas or E&E
compartments. Typically, present designs do not incorporate quick-access openings or other
such means to facilitate access to these areas.” (TSB, 2000)
The NTSB (2002) issued several recommendations to the FAA to require the enhancement of
aircraft crew training for dealing with hidden fires.
In response to the NTSB recommendations, the FAA issued AC 120-80 (2004). This AC
addressed a wide-range of issues relating to in-flight fire and smoke, including the problem of
hidden fires. This AC includes in Appendix 2, a diagram of a typical wide body aircraft
cross-section and shows various areas such as air conditioning units and ventilation airflow,
attic areas, sidewall panels, tunnel areas, cargo compartments and outflow valve(s). The FAA
has stated that the attic areas vary considerably between small regional jets and wide body
aircraft and that: “Crew members must understand the volume of overhead space in a
particular aircraft to effectively combat hidden fires in this area.”
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Actions taken by aviation agencies relating to in-flight fires, including hidden fires, are
detailed in Section 18 and in Appendix 2.
NAAs recognise that hidden fires are a significant in-flight threat (UK CAA, 2011). This is
certainly the case for the FAA (2004), who issued AC 120-80 to identify aircraft crew
training and operational issues. This is also reflected in UK CAA advisory material (2011),
although not included in EASA requirements or advisory material for aircraft crew training.
In spite of this FAA advisory material, many aircraft crew may have little or no theoretical
training on hidden fires. Fires occurring behind sidewall and ceiling panels can result in
smoke emission some distance away from the actual location of the fire. Such panels will
have to be prised open or removed in order to access the source of the fire and to discharge an
extinguishing agent. Equipment for achieving interior panel removal, such as a crash axe or
crowbar, is on many aircraft located only in the flight crew compartment. On all larger
aircraft there will be the additional issue of a locked flight crew compartment door and the
associated security procedures for access. In respect of EASA requirements, only aircraft that
have more than 200 passenger seats installed are required to have a second crash axe or
crowbar located in the passenger cabin adjacent to the aft galley. Many NAAs, including the
FAA, have no requirement for such equipment to be located in the passenger cabin. Any
practical training may be extremely limited with little information available regarding the
removal of interior panels and how best to apply extinguishing agent agents. The emission of
smoke, possibly some distance from the actual location of the fire, may result in the
extinguishing agent having little or no effect if the identification and location of the fire and
associated aircraft crew actions are remote from the actual source of the fire. This is
addressed in SAFITA Part 1 (RAeS, 2013).
UK CAA Paper 2002/01 – ‘A Benefit Analysis for Enhanced Protection from Fires in Hidden
Areas on Transport Aircraft’, clearly details the need for urgency in order for flight crew and
cabin crew to take the necessary actions to deal with an in-flight fire event.
The UK CAA (2009) has stated: “In-flight aircraft fires are a very rare occurrence but have
the potential to be catastrophic. Of particular concern are fires that originate behind cabin
walls and ceilings, where locating the fire and gaining access can be difficult.”
In July 2013 an Ethiopian Airlines Boeing 787 was involved in an incident at London
Heathrow. The aircraft had been parked for several hours on a remote stand with no
personnel on board when smoke was observed to be coming from the aft section of the
fuselage. The London Heathrow Airport Rescue and Fire Fighting Services (RFFS) were sent
to the aircraft and discovered an internal fire which they extinguished. The initial
investigation by the UK Air Accident Investigation Branch (AAIB) identified that the likely
cause of the fire was related to a fixed system Emergency Locator Transmitter (ELT)
installed in the area above Doors 4 (AAIB, 2013). Of particular interest is the following
AAIB statement:
“… large transport aircraft do not typically carry the means of fire detection or suppression
in the space above cabin ceilings and had this event occurred in flight it could pose a
significant safety concern and raise challenges for the cabin crew in tackling the resulting
fire.”
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Despite the recognised potential threat of hidden fires, very little is included in aircraft crew
mandatory training requirements by the major NAAs, although both the FAA and the UK
CAA have issued advisory material. There is no mention of hidden fires in EU-OPS or in the
EASA requirements in respect of fire training for aircraft crew. As a result many aircraft crew
may receive little or no theoretical or practical training on how to deal with an in-flight
hidden fire. They may have received little information as to the actual removal of interior
panels and how best to apply an extinguishing agent to a hidden fire. Additionally, aircraft
crew may not be aware of the problems of electrical circuits, cables and other components
that may exist behind panels where incorrect actions may have an adverse effect on electrical
systems and could make the situation worse.
The training of aircraft crew in fire-fighting and the associated procedures should take into
account, the specific types of aircraft that they operate, as well as any unique installations that
might have an impact on hidden fires, such as aircraft crew rest areas.
The FAA (2004) identified that in the case of a hidden fire, only in one third of such events
would the aircraft reach an aerodrome before the fire became uncontrollable. This clearly
identifies the risk and the urgency of the required aircraft crew actions. However, it is
questionable if this need for urgent action is effectively addressed in both theoretical and
practical fire training. Such training should also include the location of suitable additional
equipment, such as crash axe and/or crowbar. On aircraft that are only equipped with a crash
axe and/or crowbar in the flight crew compartment, training should remind cabin crew of the
availability and location of this equipment and the procedures for accessing the equipment in
an emergency. Training should include the following:
•
•
•
•
Emphasis on the danger of hidden fires and the importance of prompt action,
providing accurate information to the flight crew and the need to action the
appropriate checklists/procedures as quickly as possible;
How to safely attempt location of smoke/fire/fume sources behind panels;
The principles of how extinguishing agents work and associated fire-fighting
techniques, such as heavier-than-air extinguishers that should be applied from
above;
Dangers of, and procedures for, accessing behind aircraft panels, including the
possible location of wiring and other components.
11. Location of crash axes and crowbars
As stated previously, on aircraft with fewer than 200 passenger seats installed, the only crash
axe or crowbar mandated by the EASA requirements is located in the flight crew
compartment. For aircraft with 200 or more passenger seats installed, EASA requires the
provision of a second crash axe or crowbar to be stowed adjacent to the aft galley. The FAA
requires only one crash axe under all circumstances and the location is not prescribed.
Operators should consider the provision of an item of non-lethal equipment, to be located in
the passenger compartment so as to minimize the opening of the flight crew compartment
door and thereby maintain the smoke barrier. Such equipment could be of assistance in the
removal of panels to gain access to a hidden fire.
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12. Electrical fires
Aircraft crews are trained to deal with electrical fires in galley areas and lavatory
compartments. However, the increasing complexity of electrical installations, especially on
larger aircraft, such as In-flight Entertainment (IFE) Systems, charging systems for laptop
computers and passenger use of an ever-increasing number of PEDs should be addressed in
aircraft crew procedures and training and in particular the potential problems in dealing with
a lithium battery fire.
Additionally, premium class cabins have passenger seats that are driven by electrical motors
so as to position the seats in a variety of recline and sleeping positions. Such seats have a
high electrical load and these systems have associated circuit breakers usually located in the
cabin under the control of the cabin crew.
Each electrical system installed in an operator’s aircraft under the control of flight crew or
cabin crew should have a specific procedure to deal with an electrical failure that might result
in an in-flight fire. For each system the use and restrictions for associated circuit breakers
should be addressed and such procedures should be included in training, as applicable. The
location of circuit breakers accessible to cabin crew and the responsibility for the operation of
such equipment should be included in cabin crew training and specified in the Operations
Manual.
13. Lithium battery fires
The hazards and associated risks of lithium battery fires are covered in SAFITA Part 1
(RAeS, 2013). In recent years there has been a significant rise in the number of PEDs that
have lithium batteries as their power source. On a typical flight, an aircraft carrying 100
passengers could have more than 500 lithium batteries on board including devices such as
laptop computers, tablet devices, mobile phones, cameras, electronic watches, e-readers,
electronic flight bags, etc. Many such devices have a lithium battery as an integral sealed unit
and the battery cannot be easily replaced from a source not included in the original
manufacture and testing of the device; this might therefore reduce the risk of a lithium battery
fire in such devices.
However, lithium batteries present a potentially serious fire hazard, including fire, explosion,
smoke and fumes. It is essential that aircraft crew are trained to deal with lithium battery
fires. ICAO has issued ‘Emergency Response Guidance for Aircraft Incidents Involving
Dangerous Goods’ and this includes incidents involving PED fires with lithium battery cells
(ICAO, 2013).
Although the guidance from ICAO in Appendix 3 stresses the importance of not moving a
portable electronic device which is or has been involved in a fire (possibly involving a
lithium battery fire), it would be prudent to have an alternative procedure to deal with such an
event if it occurs in or close to the flight crew compartment. Given that most flight crew
compartments have very limited space in which to deal with a lithium battery fire, and the
proximity of the device to electronic systems and to the flight crew themselves, the retention
of the device in the flight crew compartment should be considered as a serious hazard.
Therefore, at the commander’s discretion, if he/she considers that not moving the affected
device presents a greater risk, it should be moved to an area in the passenger compartment
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where the cabin crew may more readily be able to deal with the situation. Extreme caution
should be exercised in moving the device and fire gloves together with PBE should be used
for this procedure. If PBE is not available then smoke goggles should be used instead.
Containment devices are now available on the market that may reduce the risk associated
with a PED fire. Considering the proliferation of lithium battery powered devices being
carried on board aircraft, the industry should consider evaluating the suitability of such
devices for managing PED fires in-flight. Operators that provide aircraft crew with such
devices should ensure that the procedures for their use are detailed in the Operations Manual
and that the aircraft crew are trained in their use.
14. Combi aircraft operations
Combi aircraft are configured with both passengers and cargo being carried on the main deck.
The cargo section of a Combi aircraft is separated from the passenger compartment and is
usually located in the aft section of the main deck.
Following a fatal accident in 1987 when a South African Airways Boeing 747 Combi
suffered an in-flight fire in the cargo compartment (aft of Doors 4 on the main deck), the
FAA, as well as other NAAs, introduced additional requirements for Combi aircraft,
including crew member procedures for normal and emergency situations. These requirements
included the need for additional practical training for crew members in realistic Combi
aircraft environments. (FAA, 1993; Republic of South Africa, 1990)
In the event of an in-flight fire in the cargo compartment of a Combi aircraft, intervention by
the aircraft crew may be required. Some Combi operations are undertaken in wide-bodied
aircraft and with a cargo compartment of considerable size. For example, there are usually six
or seven containers and/or pallets on a Boeing 747 main deck.
The difficulty of fighting a fire in a Combi cargo compartment is significant since it involves
a crew member:
•
•
•
•
•
•
•
•
Donning protective clothing;
Donning PBE;
Entering the cargo compartment through a cargo compartment door;
Unlatching the ‘g-net’;
Locating the large Halon fire extinguisher and lance;
Locating the source of the fire in one of the containers and/or pallets;
Extinguishing the fire;
Monitoring the area for re-ignition.
All this is to be achieved in a large and potentially unfamiliar environment and with limited
communication with the flight crew or other cabin crew members.
Operators using Combi aircraft should assess the effectiveness of their aircraft crew firefighting procedures and ensure that the required practical training fully reflects what might be
expected of an aircraft crew member in the event of an in-flight fire occurring in a cargo
compartment on a Combi configured aircraft.
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15. Fire training instructors
The qualifications and/or experience of persons conducting training and associated checking
of flight and cabin crew proficiency in responding to in-flight smoke, fire, and fumes should
be specified in the operator’s Operations Manual.
With respect to fire training, such persons should have experience in theoretical and practical
fire training, be competent in instructional techniques and have a good working knowledge of
aircraft crew operating procedures in respect of in-flight fires for the actual aircraft type(s)
and associated systems to be operated.
Suitably qualified persons should have good working knowledge of the operator’s Operations
Manual and Safety Notices relevant to aircraft crew fire-fighting procedures and equipment.
16. Third party training
Many operators outsource their aircraft crew fire training to third party training organisations.
The provision of aircraft crew fire training by a third party training organisation may result in
issues of consistency with the AOC holders Operations Manual (UK CAA, 2009).
Third party training organisations should adhere to the same standards as if the operator was
providing in-house training. The operator should audit the training to ensure full compliance
with their Operations Manual and Training Manual and that the mandatory training and
checking requirements are complied with. Again, standardisation of the training is essential.
The training and associated records provided by a third party training organisation are the
responsibility of the operator and not the third party training organisation.
Further guidance on such issues is provided in CAP 789 (UK CAA, 2011).
17. EASA cabin crew initial safety training
requirements
EASA Requirements for Initial Safety Training and Examination specifies significant
theoretical (and practical) cabin crew fire training requirements. These include:
•
•
•
•
•
•
Dealing promptly with in-flight fire and smoke events and identification of the
fire source;
Informing the flight crew and actions necessary for coordination;
Frequent checking of potential fire risk areas;
Classification of fires and use of appropriate extinguishing agents;
Practical training in fire-fighting and in the donning of smoke protection
equipment used in aviation;
Procedures of ground base emergency services.
Despite the essential nature of these requirements, they are only required to be addressed
during initial training and examination, and are therefore sometimes considered to be ‘once
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only’ training requirements. The importance of these issues should not be underestimated and
for cabin crew to be trained in these items only once may lead to a lack of competence in
subsequent years. If this training is not repeated it is probably unrealistic to expect a cabin
crew member to be able to recall items of initial training five or ten years later and could lead
to incorrect actions in the event of an in-flight fire.
Whilst some operators address some or all of these training items in recurrent training, it is
recommended that all operators do so.
The EASA requirements for cabin crew Initial Safety Training listed above are required for
the EASA Cabin Crew Attestation and are transferable between EASA AOC Holders. It
should be noted that the elements of the EASA requirements for Initial Safety Training are
generic. Moreover cabin crew Initial Safety Training might not necessarily be conducted by
an AOC Holder, but by a Third Party Training Organisation approved by the NAA to conduct
such training. Therefore, it is important that operators consider the above issues in cabin crew
Operator Aircraft Type Specific Training and Operator Conversion Training, in accordance
with the procedures and equipment relevant to the aircraft types to be operated, as specified
in the AOC Holder’s Operations Manual.
18. Actions taken by aviation safety agencies
The US National Transportation Safety Board
In 2002, the NTSB issued a review of in-flight fires. This review identified some significant
shortfalls in aircraft crew training and misinformation on the use of Halon fire extinguishers.
In one case, during an in-flight fire, the commander instructed the cabin crew not to discharge
a Halon extinguisher because he was concerned about Halon being sprayed in the cabin. In
addition, at least one operator had no emergency drill to deal with hidden fires.
The NTSB Safety Recommendations made to the FAA are in Appendix 2.
The US Federal Aviation Administration
In response to the NTSB Safety recommendations (2002), the FAA issued AC 120-80 in
2004.
A wide-range of issues are addressed by the FAA and these are included in Appendix 2.
UK Civil Aviation Authority
In the UK CAA Safety Plan of 2011/2013, a number of high risk factors for civil aviation
were identified. One of these was an in-flight fire and the UK CAA decided to conduct a
Training Needs Analysis for Cabin Crew Fire Training.
Extracts from the UK CAA Safety Plan and the Cabin Crew Training Needs Analysis and
other initiatives are in Appendix 2.
Additional advisory material on fire issues is available in UK CAA CAP 789 - Requirements
and Guidance Material for Operators (2011), UK CAA FODCOM’s and Safety Notices.
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The Transportation Safety Board of Canada (TSB)
On 2nd September 1998 Swissair MD 11, Flight Number 111, departed New York on a
scheduled flight to Geneva. The aircraft experienced a significant fire event in the flight crew
compartment and although a diversion to Halifax, Nova Scotia was commenced the aircraft
crashed into the sea. There were no survivors.
The TSB made several important statements in both their interim and final accident reports
relating to aircraft crew procedures and training in the event of an in-flight fire or smoke
event. The TSB statement regarding hidden fires can be found at Section 9. Additional
information from the TSB regarding the Swissair MD 11 accident is given in Appendix 2.
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19. Recommendations
This section describes the RAeS Flight Operations Group recommended mitigations for the
issues addressed in the previous sections regarding aircraft crew training in dealing with an
in-flight fire.
19.1 General
Recommendation 1
Any aircraft crew training for handling smoke/fire/fume events should emphasise the
priorities of the FSF checklist template: ‘protection, checklist, diversion’. In particular
the training should emphasise the urgency required in fighting an in-flight fire.
Recommendation 2
Whenever practical, flight crew and cabin crew fire training should be combined to
provide experience in effective coordination and communication between them.
Recommendation 3
When the training of aircraft crew in fire-fighting techniques has been outsourced to a
third party organisation, the operator remains responsible for the content and
consistency of such training and should ensure this through regular audit processes.
Recommendation 4
Operators’ should ensure that instructors’ assessment of crew proficiency in
extinguishing fires is standardised, especially when the equipment requires the
instructor to decide when the fire has been extinguished.
19.2 Training Equipment
Recommendation 5
Aircraft crew fire training should be realistic in terms of fire-fighting equipment,
aircraft types and operational procedures.
Recommendation 6
Extinguishing agents used in training should be chosen to replicate most closely those
used on board the aircraft to be operated.
Recommendation 7
Extinguishers used in training should require the same degree of hand pressure to
operate as operational units on board the aircraft.
Recommendation 8
Operators should verify that seals on Protective Breathing Equipment (PBE) used in
training are effective and replicate PBE carried on board the aircraft.
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Recommendation 9
The difficulties in fighting a fire whilst simultaneously using fire extinguishers, PBE
and fire gloves in a real fire situation on board an aircraft should be reflected as far as
possible in training.
Recommendation 10
Practical fire training should demonstrate the actual difficulties in communicating
either face-to-face or by interphone with other aircraft crew members whilst wearing
protective equipment.
Recommendation 11
Operators that provide aircraft crew with containment devices should ensure that the
procedures for their use are detailed in the Operations Manual and that the aircraft
crew are trained in their use
19.3 Fire Training Scenarios
Recommendation 12
Operators should use realistic scenarios in training that follow the full sequence of
events to an appropriate conclusion.
Recommendation 13
Operators should use training scenarios that require on-going communication between
the cabin crew and flight crew as the scenario develops.
Recommendation 14
For operations without cabin crew, flight crew training should include the procedures
for transferring from cockpit smoke protection to portable protection equipment.
Recommendation 15
For operations without cabin crew, flight crew training should include the procedures
for passenger handling in a smoke/fire/fumes event.
Recommendation 16
Operators should ensure that there is regular and effective communication between
the instructional team for aircraft crew safety and emergency procedures training and
the flight crew instructional team for flight crew simulator training.
Recommendation 17
Flight crew training should emphasise that if the source of the fire is not confirmed
visually to be extinguished after initial actions the flight crew should initiate a
diversion.
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Recommendation 18
Flight crew oxygen mask training should ensure complete familiarity for use in an
emergency situation.
Recommendation 19
The problems and procedures for dealing with hidden fires, lithium battery fires, flight
crew compartment fires and crew rest compartment fires should be addressed in
practical fire training.
Recommendation 20
In Combi aircraft, the special difficulties associated with access to and unfamiliarity
of crews with cargo compartments should be stressed in training.
Recommendation 21
Aircraft crew training should include an understanding of the vital requirement of
maintaining a smoke barrier between the fight crew compartment and the passenger
compartment (i.e. the flight crew compartment door).
Recommendation 22
Operation of circuit breakers to isolate an electrical circuit and limit the continued
ignition source of the fire should be addressed in both flight crew and cabin crew
training together with the restrictions on their use.
Recommendation 23
Where a flight requires only one cabin crew member, he/she should be trained in the
responsibilities and difficulties of managing a cabin fire situation and operators
should develop specific procedures for dealing with an in-flight fire in such
circumstances.
Recommendation 24
Where a flight is permitted to operate without any cabin crew, operators should
develop specific procedures and training for flight crew to deal with an in-flight fire
and any passengers on-board.
19.4 Regulatory Improvements
Recommendation 25
NAAs should conduct a comprehensive review of aircraft crew fire training
requirements in light of SAFITA Part 2: Training, as well as other industry initiatives,
and determine the need for future rule-making in the long term and the issuing of
advisory material in the short term.
Recommendation 26
EASA should review their fire training requirements and determine what changes
might be appropriate to address the problems for aircraft crews in dealing with hidden
in-flight fires.
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Recommendation 27
The EASA requirements (and, if applicable, other NAA requirements) for cabin crew
initial fire training should be repeated on a three-year cycle to ensure continued
competence.
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20. References
AAIB. (2005). Cessna 550 Citation 11, G-VUEA. AAIB Bulletin 3/2005. 38-44. AAIB
AAIB. (2013). Boeing 787-8, ET-AOP. AAIB Special Bulletin S5/2013. AAIB
Cardosi, K. M., & Huntley, M. S. (1988). Cockpit and Cabin Crew Coordination. FAA
FAA. (1993). Airworthiness Directive 93-07-15, Amendment 39-8547. FAA
FAA. (2004). In-flight Fires. AC 120-80. FAA
FSF. (2005). Flight Crew Procedures Streamlined for Smoke/Fire/Fumes. Flight Safety
Digest. 24 (6), 31-36.
ICAO. (2013). Emergency Response Guidance for Aircraft Incidents Involving Dangerous
Goods. Doc 9481 – AN/928. ICAO
NTSB. (1986). Aircraft Accident report Air Canada McDonnell Douglas DC-9-32. Retrieved
from http://www.ntsb.gov/investigations/summary/AAR8602.html
NTSB. (2002). A-01-83 through -87: Recent In-flight Fires. Washington: NTSB
RAeS. (2013). Smoke, Fire and fumes in Transport Aircraft Part 1: Reference. London:
RAeS
Republic of South Africa. (1990) Report of the Board of Inquiry into the Helderberg Air
Disaster. Pretoria: Government Printer
Taylor, P. M. Rt. Hon Lord Justice. (1989). The Hillsborough Stadium Disaster. London:
HMSO
TSB. (2000). Interim Air Safety Recommendations. Retrieved from
http://www.tsb.gc.ca/eng/medias-media/sur-safe/recommandationsrecommendations/feu-fire_2000dec4.asp
UK CAA. (2001). CAA Paper 2002/01: A Benefit Analysis for Enhanced Protection from
Fires in Hidden Areas on Transport Aircraft. Gatwick: UK CAA.
UK CAA. (2009). Cabin Crew Fire Training - Training Needs Analysis. Gatwick: UK CAA.
UK CAA. (2009). CAA Works with Airlines on Fire Training Policy. CAA Newsroom.
Retrieved from:
http://www.caa.co.uk/application.aspx?catid=14&pagetype=65&appid=7&newstype=
n&mode=detail&nid=1727
UK CAA. (2013). Aviation regulators launch joint fire safety initiative. CAA Newsroom.
Retrieved from:
http://www.caa.co.uk/application.aspx?catid=14&pagetype=65&appid=7&newstype=
n&mode=detail&nid=2265
UK CAA, (2011). CAP 789. Requirements and Guidance Material for Operators. Gatwick:
UK CAA
UK CAA. (2011). Safety Plan 2011 to 2013. Gatwick: UK CAA
UNEP. (2007). The Montreal Protocol on Substances that Deplete the Ozone Layer. UNEP
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Appendix 1
The EASA Requirements for Cabin Crew Fire Training and Suggested Guidance Material
Appendix 1 to Part-CC – Initial training course and examination
The EASA Requirements
Guidance on Meeting the EASA Requirements
8. Fire and smoke training:
8.1. emphasis on the responsibility of
 Importance of in-flight fires and the need to identify the exact fire source wherever it might be
cabin crew to deal promptly with
located, i.e. all areas of the aircraft accessible to the crew during flight.
emergencies involving fire and smoke
 Identification of the location of the fire and its intensity, the amount of smoke being produced,
and, in particular, emphasis on the
and associated smells that might provide indications as to fire source;
importance of identifying the actual
 All such information to be communicated to the SCCM and to the flight crew by the cabin crew.
source of the fire;
 The need for immediate and urgent action in dealing with an in-flight fire.
 The limited amount of time available for achieving a successful outcome using case studies
where appropriate.
 Passenger management and crowd control.
 Specific procedures for dealing with fires involving aircraft systems.
App 1-1
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8.2. the importance of informing
 Specific procedures for communication and coordination with the flight crew and other cabin
the flight crew immediately, as
crew members and the specific actions required to deal with an-flight fire.
well as the specific actions
 For operations with only one cabin crew member, particular importance on fire-fighting and
necessary for coordination and
communication procedures, including criteria for requesting assistance from dead-heading crew
assistance, when fire or smoke is
members and if necessary passengers.
discovered;
 Actual communications between cabin crew and flight crew, taking into account the lack of
face-to-face communication imposed on many aircraft by the locked/secured flight crew
compartment door and reliance on communication via interphone.
 Communication of the essential information to the flight crew regarding an in-flight fire, so that
the flight crew can make well-informed decisions as to an emergency descent and/or diversion.
 Essential information to be communicated by the cabin crew to the flight crew, including the
following:
a. Which crew member is speaking and from what location;
b. The location of the fire and source of the fire and any associated smell.
c. The size of the fire and the amount and colour of the smoke being produced;
d. The cabin crew actions being undertaken and the number of fire extinguishers used;
e. Passenger reaction, and cabin crew actions to control the situation; and
f. The development of the event, when the fire is extinguished, and the conduct of post-fire
procedures.
 That the high level of work-load on the flight crew will be extremely demanding during an inflight fire event and that information passed to the flight crew by the cabin crew needs to be
clear and concise, and relevant to the situation.
 The occurrence of multiple fires in different areas of the passenger cabin or areas accessible to
passengers and crew during flight including multi-deck aircraft.
 The options for cabin crew to deviate from specific emergency procedures to deal with differing
fire situations.
8.3.
the necessity for frequent
 The location of potential fire-risk areas and the required frequency of the checking of such areas
checking of potential fire-risk areas
including the visual checking of associated smoke detectors.
including toilets, and the associated
 Best practice for fire-prevention to include all galley and other electrical systems as well as
smoke detectors;
restrictions on the use and re-setting of circuit breakers under the control of cabin crew.
App 1-2
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8.4
the classification of fires and
the
appropriate
type
of
extinguishing
agents
and
procedures for particular fire
situations;
8.5. the techniques of application
of extinguishing agents, the
consequences of misapplication,
and of use in a confined space
including practical training in firefighting and in the donning and use
of smoke protection equipment
used in aviation; and
8.6. the general procedures of
ground-based emergency services
at aerodromes.
 Basic fire chemistry (The Fire Triangle) – oxygen; heat; fuel.
 Classes of fires and associated types of extinguishers. Alternative methods of fire-fighting using
equipment/resources other than fire extinguishers.
 Optimum use of each type of extinguisher carried on the aircraft, to include the limited amount
of extinguishment carried, especially in the case of smaller aircraft.
 The training in fire-fighting and donning of smoke protection equipment (i.e. PBE) will need to
be covered in detail during Aircraft type specific training, and Operator conversion training.
 Third-party training organisations will need to take this into consideration, although the use of
any fire extinguishers and PBE will not necessarily be consistent with the equipment carried on
board by the operator.
 Training to be undertaken in association with, or advice from, local airport Rescue and Fire
Fighting Services (RFFS), to the general procedures of ground-based emergency services at
aerodromes, including the use of standard emergency hand signals by rescue and fire-fighting
service personnel;
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ORO.CC.125 – Aircraft type specific training and operator conversion training
(c). the aircraft type specific training
programme shall:
(c) (2). cover at least the following
 All equipment that might be used in fire-fighting and the exact location of such equipment to
aircraft
type
specific
training
include, fire extinguishers, PBE, torches, protective clothing such as fire gloves, crash axes
elements:
and/or crowbars, etc.
(i) aircraft description as relevant to
cabin crew duties;
(ii) all safety equipment and systems
installed relevant to cabin crew
duties;
(v)
fire and smoke protection
equipment where installed.
(d). (3) cover at least the following
 A detailed description of the cabin configuration to include the location of fire risk areas
operator specific training elements as
such as lavatory compartments, galleys, crew rest areas, etc., as well as the location of circuit
relevant to the aircraft type to be
breakers in cabin areas and the restrictions on the re-setting of circuit breakers.
operated:
(i)
description of the cabin
configuration;
(ii) location, removal and use of all
portable safety and emergency
equipment carried on board;
 See AMC1 ORO.OPS.CC.125(d).
(v) fire and smoke training including
the use of all related fire-fighting and
protective equipment representative
of that carried on board;
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AMC1 ORO.CC.125(c) – Aircraft type specific training and Operator conversion training – Training
Programme – Aircraft Type Specific Training
The EASA Requirement
(d)
Fire and smoke protection
 See AMC1 ORO.OPS.CC.125(d).
equipment.
Each cabin crew member should be
trained in using fire and/or smoke
protection equipment where fitted.
App 1-5
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AMC1 ORO.OPS.CC.125(d) – Aircraft type specific training and Operator conversion training
(b)
Safety and emergency
 Training to include the type(s) of fire-fighting equipment carried on each aircraft type(s) and
equipment.
variant(s) to be operated and include specific cabin configurations such as crew rest areas,
Each cabin crew member should
lavatory compartments, galleys, cargo areas accessible to the cabin crew during flight, etc.
receive realistic training on and
 Each cabin crew member to demonstrate their knowledge on the location and use of all firedemonstration of the location and use
fighting equipment and demonstrate their ability to remove such equipment from the different
of all safety and emergency
stowage areas found on the aircraft type(s) and variant(s) to be operated.
equipment carried including:
 The fire-fighting equipment to be representative of that carried on the aircraft type(s) and
(3) fire extinguishers and protective
variant(s) to be operated.
breathing equipment (PBE);
 Fire extinguishers that are not representative in terms of weight, size or operation, to those carried
(4) crash axe or crowbar;
on the aircraft type(s) or variant(s), are not to be used in any part of training.
(5)
emergency lights including
 Differences in fire extinguishers used in training may be necessary in order to overcome the
torches;
restrictions on Halon discharge in order to meet the requirements of the Montreal Protocol. Any
(6)
communication equipment,
differences in equipment are to be specified in the Operations Manual (OM) and stressed during
including megaphones;
training.
 The use of fire axes and crowbars to access hidden fires is to be addressed in practical training.
(10).
other portable safety and
 Alternative means of accessing hidden fires is to be specified.
emergency
equipment
where
 Galley and other electrical systems in the cabin and areas accessible to cabin crew during flight,
applicable
to be included in training as well as restrictions on the use and re-setting of circuit breakers.
 The location of circuit breakers accessible to cabin crew and responsibility for such equipment to
be included in training and specified in the OM procedures.
App 1-6
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(c)
Normal and emergency
procedures.
Each cabin crew member should be
trained on the operator’s normal and
emergency procedures as applicable
with emphasis on the following:
(4) Other in-flight emergencies.
(e) Fire and smoke training:
(1) Each cabin crew member should
receive realistic and practical training
in the use of all fire-fighting
equipment
including
protective
clothing representative of that carried
in the aircraft;
 Training to include an in-flight fire, with particular emphasis on identifying the actual source of
the fire taking into account the systems and installations relevant to the aircraft type(s) and
 Training to include all relevant fire scenarios and address flight crew compartment fires and fires
in cargo areas as well as other areas which are accessible to the cabin crew during flight.
 Training to identify not only the nature of the fire, and its source and location, but also its
intensity, and the amount of smoke that is being produced, as well as the effective use of all firefighting equipment.
 The occurrence of multiple fires in different areas of the passenger cabin or areas accessible to
crew during flight.
 Cabin crew fire training to include communications and coordination with the flight crew and
other cabin crew by use of the interphone and also the difficulties of communication whilst
wearing PBE.
 When combined flight crew and cabin crew is not conducted, there needs be an effective liaison
between both training departments so as to ensure consistent in-flight procedures as specified in
the OM and in related flight crew procedures and documentation.
 The fire-fighting equipment to be representative of that carried on the aircraft type(s) and
App 1-7
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(2) Each cabin crew member should:
(i) extinguish an actual
fire
characteristic of an aircraft interior
fire except that, in the case of halon
extinguishers,
an
alternative
extinguishing agent may be used;
 Each cabin crew member demonstrates their ability to extinguish an actual fire.
 If more than one type of fire extinguisher is carried on the aircraft type(s) or variant(s), each type
of extinguisher will need to be used in practical training by each cabin crew member.
 Fire extinguishers that are not representative in terms of weight, size or operation, to those carried
on the aircraft type(s) or variant(s), not to be used in any part of training.
restrictions on Halon discharge in accordance with the requirements of the Montreal Protocol.
Any differences in equipment are to be specified in the OM and stressed during training.
 Some fire extinguishers require additional pressure to break the fire extinguisher seal, to the
amount of pressure that is experienced with a training unit. When practicable, such pressure will
need to be replicated on training units. When not practicable, the differences will need to be
stressed in training.
 The size of the fire will need to present the cabin crew with an actual challenge in terms of
extinguishing the fire. Fires that are easily extinguished might result in a false sense of security.
 Fires scenarios will need to be consistent with installations on the aircraft type(s) and variants(s)
to be operated.
 Where ‘gas-powered’ fire training rigs are utilised, the specific use of them will need to be
specified in the OM especially in cases where the instructor actually terminates the supply of the
gas. Specific criteria is to be specified in the OM as to when the gas supply is terminated in order
to ensure that the cabin crew member has clearly demonstrated proficiency.
 Hidden fires and access to hidden fires will need to be addressed in practical training.
 Combination of practical fire extinguisher training with practical PBE training and the use of
protective clothing such as fire gloves.
 Cabin crew fire training will include communication and coordination with the flight crew and
other cabin crew by use of the interphone system and the difficulties of communication whilst
wearing PBE.
 Fire re-ignition will be dealt with on practical level.
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(ii) exercise the donning and use of
PBE in an enclosed, simulated smokefilled environment with particular
emphasis on identifying the actual
source of fire and smoke.
 Each cabin crew member will need to demonstrate their ability to don PBE, and to use it in an
enclosed simulated smoke-filled environment.
 If more than one type of PBE is carried on the aircraft type(s) or variant(s) to be operated, each
type of PBE will need to be used in practical training by each cabin crew member.
 The removal of PBE from its container and packaging will need to be addressed in training. This
may need to be achieved by a suitable training video or other media facility.
 Special attention will need to be paid to PBE neck seals and their integrity so as to ensure a level
of difficulty of donning that would be encountered with an operational unit.
 The density of the smoke-filled environment will need to be a standard specified in the OM –
suggested criteria might be a specified number of visible seat rows.
 The time spent in a smoke-filled environment by each cabin crew member will need to be a
standard specified in the OM.
 Practical PBE training will need to be conducted in conjunction with practical fire extinguisher
training, as well as communication and coordination by use of the interphone.
 All aspects of cabin crew fire training will need to include communications and communication
with the flight crew and other cabin crew by use of the interphone, and include communication of
only essential information.
App 1-9
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ORO.CC.140 – Recurrent Training
(a) Each cabin crew member shall complete annually
recurrent training and checking.
(b) Recurrent training shall cover the actions
 Emergency procedures should include in-flight fires and different fires
assigned to each member of the cabin crew in normal
scenarios depending on the aircraft type as well as the facilities and the
and emergency procedures and drills relevant to each
installations on-board including electrical systems in the passenger cabin.
aircraft type and/or variant to be operated.
(d) Operator specific training elements:
(1) Recurrent training shall include annually:
(i) by each cabin crew member
(A) Location and handling of all safety and
 Such training might necessitate a visit(s) to the actual aircraft type(s) and
emergency equipment installed or carried on board;
variants(s) to be operated. Aircraft visit(s) will need to be specified in the
and
CCTM.
(B) the donning of life-jackets, portable oxygen and
 If more than one type of PBE is carried, each cabin crew member will need to
protective breathing equipment (PBE).
don each type of PBE.
(iv) emergency procedures;
(2) Recurrent training shall also include at intervals
not exceeding three years:
(iii) realistic and practical training in the use of all
fire-fighting equipment, including protective
clothing, representative of that carried in the aircraft;
(iv) by each cabin crew member:
(A) extinguishing a fire characteristic of an aircraft
 See the detail in AMC1 ORO.CC.140 – Recurrent Training.
interior fire;
(B) donning of PBE in an enclosed simulated
 See the detail in AMC1 ORO.CC.140 – Recurrent Training.
smoke-filled environment.
App 1-10
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AMC1 ORO.CC.140 – Recurrent Training – Training Programmes
(a) Elements of annual recurrent
training programme
(1) Training on the location and
 Such training may necessitate a visit(s) to the actual aircraft type(s) and variant(s) to be operated.
handling of safety and emergency
Aircraft visits will need to be specified in the OM.
equipment should include all relevant
 If more than one type of PBE is carried, each cabin crew member will need to don each type of
oxygen systems, and any equipment
PBE.
such as defibrillators if carried on
board.
(2)
Training on emergency
 Review of the fire related items required for Initial training course and examination.
procedures should cover pilot
incapacitation procedures and crowd
control techniques.
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(b) Additional triennial elements of
training
(2) Training in the use of all fire Each cabin crew member will need to demonstrate their ability to extinguish an actual fire.
fighting
equipment,
including
 If more than one type of fire extinguisher is carried, each type of extinguisher will need to be
protective clothing, representative of
used in practical training by each cabin crew member.
that carried in the aircraft should
include individual practice by each
restrictions on Halon discharge in accordance with the requirements of the Montreal Protocol.
cabin crew member to extinguish a
Any differences in equipment will need to be specified in the OM and stressed in training.
fire characteristic of an aircraft
 Some fire extinguishers require additional pressure to break the fire extinguisher seal to that
interior fire except that, in the case of
experienced with a training unit. When practicable such pressure will need to be replicated on
halon extinguishers, an alternative
training units. When not practicable, the differences will be stressed in training.
extinguishing agent may be used.
 The size of the fire will need to present the cabin crew with an actual challenge in terms of
Training should place particular
extinguishing the fire. Fires that are easily extinguished might result in a false sense of
emphasis on identifying the actual
security.
source of fire or smoke.
 The actual size of the fire and the fire source used in the training will need to be described in
the OM together with level of difficulty to extinguish the fire, together with different fire
scenarios.
 Fires scenarios will need to be consistent with installations on the aircraft type(s) and
 Fire re-ignition will need to be dealt with on a practical level.
 Where ‘gas-powered’ fire training rigs are utilised, the specific use of them will need to be
specified in the OM especially in cases where the instructor actually terminates the supply of
the gas. Specific criteria will need to be specified in the OM as to when the gas supply is
terminated in order to ensure that the cabin crew member has clearly demonstrated
proficiency.
 Hidden fires to be addressed in practical training.
 Practical fire extinguisher training to be combined with practical PBE training and the use of
protective clothing such as fire gloves.
 Cabin crew fire training to include communications and coordination with the flight crew and
other cabin crew by use of the interphone.
App 1-12
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 Each cabin crew member to demonstrate their ability to don and use PBE in an enclosed
simulated smoke-filled environment.
 If more than one type of PBE is carried on the aircraft or variant, each type of PBE to be used
in practical training by each cabin crew member.
 The removal of PBE from its container and packaging to be addressed in training. This may
need to be achieved by a suitable training video or other media facility.
 Special attention to be paid to PBE neck seals and their integrity to be such so as to ensure a
level of difficulty of donning that would be encountered with an operational unit.
 The density of the smoke-filled environment to be a standard specified in the OM – suggested
criteria might be a specified number of seat rows.
 The time spent in a smoke-filled environment by each cabin crew member to be a standard
specified in the OM.
 Practical PBE training to be conducted in conjunction with practical fire extinguisher training,
as well as communication and coordination by use of the interphone.
 All aspects of cabin crew fire training to include communications and coordination with the
flight crew and other cabin crew by use of the interphone, including communication of
essential information.
 When combined flight crew and cabin crew training is not conducted there will need to be an
effective liaison between both training departments so as to ensure consistent in-flight
procedures as specified in the OM.
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ORO.CC.115 – Conduct of training courses and associated checking
(a) A detailed programme and syllabus shall be
 The check of fire-training proficiency will need to address each element of
established by the operator for each training course in
required theoretical and practical training.
accordance with the applicable requirements of this
 Where it is not possible to conduct certain practical proficiency checks, these
Subpart, and of Annex V (Part-CC) to Regulation
items will need to be specific reference in the OM and be addressed by
(EU) No 290/2012 where applicable, to cover the
alternative means of training and checking, e.g. removal of PBE from its
duties and responsibilities to be discharged by the
packaging.
cabin crew members.
 In the case of Third Party Training, a clear understanding between the
(b) Each training course shall include theoretical and
operator and the Third Party Training organisation will need to be established
practical instruction together with individual or
as to the level of required proficiency.
collective practice, as relevant to each training subject,
 Operators should ensure that the EASA requirements are clearly stated in
in order that the cabin crew member achieves and
cabin crew training record forms, or by specific reference to the syllabi in the
maintains the adequate level of proficiency in
OM.
accordance with this Subpart.
 Simply stating in training records that ‘fire and smoke training’ has been
completed does not necessarily comply with the EASA practical training
(c) Each training course shall be:
requirements.
(1) conducted in a structured and realistic manner; and
 Third Party Training organisations will need to ensure that the training
(2) performed by personnel appropriately qualified for
records that they produce are fully in accordance with the individual
the subject to be covered.
operator’s requirements and documentation.
(d) During or following completion of all training
 Fire training records produced by Third Party Training Organisations are the
required by this Subpart, each cabin crew member
responsibility of the operator.
shall undergo a check covering all training elements of
the relevant training programme, except for crew
resource management (CRM) training, Checks shall
be performed by personnel appropriately qualified to
verify that the cabin crew member has achieved and/or
maintains the required level of proficiency.
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Appendix 2
Actions taken by aviation safety agencies in respect of inflight fire
The US National Transportation Safety Board
In a review of in-flight fires in 2002, the NTSB made the following Safety Recommendations
to the FAA:
•
“Issue an AC that describes the need for crewmembers to take immediate and
aggressive action in response to signs of an in-flight fire. The AC should stress that
fires are often hidden behind interior panels and therefore may require a crew member
to remove or otherwise gain access to the area behind interior panels in order to
effectively apply extinguishing agents to the source of the fire. (A-01-83)”
•
“Require Principle Operations Inspectors to ensure that the contents of the
advisory circular (recommended in A-01-83) are incorporated into crewmember
training programmes. (A-01-84)”
•
“Amend 14 Code of Federal Regulations 121.417 to require participation in
fire fighting drills that involve actual or simulated fires during crewmember recurrent
training and to require that those drills include realistic scenarios on recognizing
potential signs of locating, and fighting hidden fires. (A-01-85)”
•
“Develop and require implementation of procedures or airplane modifications
that will provide the most effective means for crewmembers to gain access to areas
behind interior panels for the purpose of applying extinguishing agent to hidden fires.
As part of this effort, the FAA should evaluate the feasibility of equipping interior
panels of new and existing airplanes with ports, access panels, or some other means
of applying extinguishing agent behind interior panels. (A-01-86)”
•
“Issue a flight standards handbook bulletin to principle operations inspectors
to ensure that air carrier training programs explain the properties of Halon and
emphasize that the potential harmful effects on passengers and crew are negligible
compared to the safety benefits achieved by fighting in-flight fires aggressively. (A01-87)”
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The Federal Aviation Administration
In response to the NTSB safety recommendations, the FAA issued AC 120-80 in 2004.
In this AC the FAA addressed:
•
•
•
•
•
•
•
•
•
•
•
The dangers of in-flight fires and in particular hidden fires;
The need for rapid assessment of the situation and the taking of immediate and
aggressive action;
The gaining of access behind panels;
The effectiveness of Halon as an extinguishing agent;
Definitions associated with fire;
Cause and indications of in-flight fires;
Alternative resources available for fighting a fire;
Types of hand-held fire extinguishers and their operation;
Possible harm to passengers of exposure to Halon discharge;
Flight crew and cabin crew actions;
Restrictions on the use/resetting of circuit breakers.
This clearly demonstrates the need for urgency in order for aircraft crew to take the necessary
actions to deal with an in-flight fire event and that in only one third of such instances will the
aircraft reach a suitable alternate aerodrome before the fire becomes uncontrollable.
The table below, taken from Appendix 3 in the FAA AC 120-80, shows the time that various
aircraft crew had in actual incidents between the first indication of fire, to the point when the
fire became catastrophically uncontrollable. Also that for aircraft with hidden fires, an
approximate assessment is that only one third will reach a suitable aerodrome before the fire
becomes uncontrollable.
Date:
July 1969
July 1973
November 1973
November 1979
June 1983
November 1987
September 1998
Location:
Biskra, Algeria
Paris, France
Boston, USA
Aircraft Type:
Caravelle
Boeing 707
Boeing
707
(Cargo)
Jeddah, Saudi Arabia Boeing 707
Cincinnati, USA
Douglas DC-9
Mauritius,
Indian Boeing
747
Ocean
(Combi)
Nova Scotia, Canada Douglas MD-11
Time to become non-survivable:
26 minutes
7 minutes
35 minutes
17 minutes
19 minutes
19 minutes
16 minutes
The average ‘Time to become ‘non-survivable’ in the above accidents is just 20 minutes. In
spite of this worrying statistic there is no reference in the EASA requirements for aircraft
crew training to address the issue of hidden fires, either as a requirement for theoretical
training or practical training, nor has any guidance material been issued by EASA.
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Three additional fire-related accidents are worthy of note as follows:
•
•
•
UPS, DC-8 in-flight and post ground fire accident in Philadelphia, 8 February
2006;
UPS, Boeing 747-400F in-flight fire accident, 3 September 2010, departing
Dubai for Cologne;
Asiana, Boeing 747-440F in-flight fire accident, 28 July 2011, departing
Incheon, South Korea, for Shanghai in China.
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The UK Civil Aviation Authority
UK CAA - Safety Plan of 2006/2007
The UK CAA Safety Plan stated: “The CAA believes that the current training practices and
standards may no longer [be] totally appropriate; recent accident experience indicates that
consideration should be given to the implications of more substantial cabin fire than
currently trained. In addition the introduction of locked flight crew compartment security
doors could have an implication for training procedures. The possibility of multiple,
simultaneous fires should also be considered in training.”
UK CAA – Cabin Crew Training Needs Analysis
The Training Needs Analysis was conducted by an independent organisation and the results
of the work were published in UK CAA Paper 2009/01 – Cabin Crew Fire Training –
Training Needs Analysis, conducted by Ray Cherry and Associates – Aeronautical and Safety
Engineers (UK CAA, 2009).
The purpose of the Analysis was: “To evaluate current and possible future issues, and
identify potential improvements to existing fire training in order to ensure that cabin crew
members have the most appropriate training and procedures to match current and likely fire
threats.”
In March 2009, the UK CAA made the following statements in respect of the Cabin Crew
Fire Training Analysis:
“One of the most serious threats in air transportation today is an in-flight fire. Cabin
crew and flight crew actions are the primary line of defence in such an occurrence and it is
therefore essential that they have the most appropriate training to deal with the threat.”
“In-flight aircraft fires are a very rare occurrence but have the potential to be
catastrophic. Of particular concern are fires that originate behind cabin walls and ceilings,
where locating the fire and gaining access can be difficult.”
“As the cabin environment is always changing, with new aircraft – such as the A380
– being introduced, the UK CAA considered it timely to review overall cabin crew training
needs to ensure cabin crew have the necessary skills to deal with current and future fire
threats.”
“The UK CAA will work with the European Aviation Safety Agency (EASA) to develop
European-wide safety rules, and with UK operators to ensure that best fire training advice is
available.”
“As the safety regulator for UK operators, we must ensure that cabin crew receive fire
fighting training that is both adequate and appropriate. As the aviation industry continues to
evolve, new fire threats emerge that must be considered. The study indicates that there are a
number of issues to consider for the future and we will be working with the UK industry and
our European partners to provide guidance.”
A cross-section of operators was visited during the Training Needs Analysis; most were UK
operators, but some non-UK operators were also involved.
The UK CAA determined that the main findings of the analysis were:
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
In-flight fires were a serious threat;
Cabin crew were the first line of defence and that flight crew had little control
over an in-flight fire situation;
Training should be appropriate and effective;
Fire extinguishers and PBE used in training were not always representative to
those carried on board the aircraft to be operated;
Some operators had more than one type of fire extinguisher and more than one
type of PBE;
The removal of PBE from packaging was not practised;
Discharge of Halon was not easily replicated because of restrictions imposed by
the Montreal Protocol;
The severity of fire encountered in training, differed between operators and
training organisations;
There was a need for training to deal with fire re-ignition – otherwise training
might encourage a false sense of security;
PBE used in training was often damaged – especially in the case of PBE neck
seals;
Practical PBE training was not usually combined with practical fire-fighting
training;
The time spent by aircraft crew in smoke whilst wearing PBE differed between
20 seconds and seven minutes, the density of smoke differed significantly, and
smoke scenarios were not always appropriate or realistic;
Where joint training was not conducted there was a need for close and effective
liaison between flight crew and cabin crew training departments;
Fire training needs to be in compliance with the requirements of the operator
and appropriate to the operation;
Some important aspects of theoretical fire training were only required by the
EASA requirements to be carried out once, i.e., during initial training;
Hidden fires were not always addressed in training.
The analysis also identified further questions as follows:
•
•
•
•
•
•
•
•
•
•
Was the type of fire appropriate to the operation of the aircraft and its
installations?
If gas rigs are used, what criteria were there for the instructor to terminate the
gas supply?
Were multiple fires addressed in training?
Were communications issued addressed in PBE training, i.e., use of the
interphone and PA whilst actually wearing PBE?
Should cabin crew wear their uniform when conducting fire training?
In the case of single cabin crew operations, was the effectiveness of operational
procedures and training for fighting an in-flight fire actually addressed by
operators?
Was removal of fire-fighting equipment from stowage(s) practised by individual
cabin crew?
Was the management and control of passengers included in fire scenarios?
Was Third Party Training controlled and regularly audited by the operator?
Was Third Party Training reviewed on a regular basis by the operator in order
to ensure that changes to procedures and equipment were addressed?
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•
Did Third Party training organisations have access to the relevant parts of the
Operations Manual?
The main conclusions of the analysis were:
•
•
•
•
•
•
There was lack of definition of some of the EASA requirements and there was
lack of advisory material issued by EASA;
Many operators did more than the EASA requirements;
There were few criteria for the checking of proficiency;
Combined flight crew and cabin crew training to deal with in-flight fires should
be increased;
There was a need to incorporate CRM issues into fire training;
Health and Safety issues needed to be addressed in fire training.
In May 2009, the UK CAA organised an industry working group to look at the above
findings and conclusions in order to develop advisory material (UK CAA, 2009). The
working group presented their material to the CAA in the late summer of 2009. Resulting
from this the UK CAA issued FODCOM 19/2010 ‘Cabin Crew Fire and Smoke Training’.
Note: Although the UK CAA Training Needs Analysis was conducted primarily in respect of
cabin crew, many of the findings and conclusions are equally appropriate to flight crew
procedures and training.
In August 2013 the CAA announced the launch of a joint fire safety initiative with the FAA
(UK CAA, 2013). Although the film that has been produced by both agencies is related to
the importance of compliance with maintenance procedures, the UK CAA made the
following important statements:
“Indeed, the CAA has previously identified fire as one of the ‘significant seven’ safety risks to
commercial aviation, along with such threats as ‘loss of control’ and ‘runway excursions’. Of
particular concern is the threat of fires breaking out in hidden areas of the aircraft, which
cabin crew are unable to access and bring under control in-flight. The importance of
reducing fire risks was highlighted with the recent significant fire on the Ethiopian Airlines
Boeing 787 on the ground at London Heathrow. As the film points out, an in- flight fire that
is out of control will on average lead to the flight crew losing control of the aircraft within 15
minutes.”
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The Transportation Safety Board of Canada (TSB)
The Swissair MD 11 Accident
The TSB in their 2000 interim aviation safety recommendations – In-flight fire-fighting –
Swissair Flight 111 (MD11), stated:
“The TSB review of SR 111 and other in-flight fire occurrences has shown that where an inflight fire continues to develop, there is little time between detection of the fire and the loss of
aircraft control. It must be anticipated that aircraft systems will be affected, either as a direct
result of the fire, or as a result of emergency procedures such as the de-powering of
electrical busses. It is imperative that fire fighting procedures be well defined and that
aircraft crews be well trained in handling all in-flight fires.”
“Although aircraft crews are trained to fight in-flight fires, there are no requirements that
cabin and flight crews train together, or that they be trained to follow an integrated firefighting plan and checklist procedure. For example, neither flight crews nor cabin crews are
trained to fight in-flight fires in the cockpit. Several operators contacted by the TSB indicate
that flight crews and cabin crews do not receive training specific to fighting fire in the
cockpit. The division of roles and responsibilities between flight and cabin crews with respect
to who will be combating an in-flight fire in the cockpit is not clearly defined in manuals and
company procedures.”
Additionally the TSB in their final accident investigation report A98H0003 (TSB, 2003),
made the following statements:
“Conclusions - Findings as to Causes and Contributing Factors”
“There was a reliance on sight and smell to detect and differentiate between odour or smoke
from different potential sources. This reliance resulted in the misidentification of the initial
odour and smoke as originating from an air conditioning source.”
“There was no integrated in-flight fire-fighting plan in place for the accident aircraft, nor
was such a plan required by regulation. Therefore, the aircraft crew did not have procedures
or training directing them to aggressively attempt to locate and eliminate the source of the
smoke, and expedite their preparations for a possible emergency landing. In the absence of
such a fire-fighting plan, they concentrated on preparing the aircraft for the diversion and
landing.”
“Conclusions – Other Findings”
“Coordination between the pilots and the cabin crew was consistent with company
procedures and training. Crew communications reflected that the situation was not being
categorized as an emergency until about six minutes prior to the crash; however, soon after
the descent to Halifax had started, rapid cabin preparations for an imminent landing were
underway.”
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“Safety Action – In-flight fire-fighting”
“Along with initiating the other elements of a comprehensive fire-fighting plan, it is essential
that flight crews give attention, without delay, to preparing the aircraft for a possible landing
at the nearest suitable airport. Therefore, the TSB made the following recommendation:
Appropriate regulatory authorities take action to ensure that industry standards reflect a
philosophy that when odour/smoke from an unknown source appears in an aircraft, the most
appropriate course of action is to prepare to land the aircraft expeditiously. A00-18 (issued 4
December 2000)”
“An uncontrollable in-flight fire constitutes a serious and complicated emergency. A fire may
originate from a variety of sources, and can propagate rapidly. Time is critical. Aircraft
crews must be knowledgeable about the aircraft and its systems, and be trained to combat
any fire quickly and effectively in all areas, including those that may not be readily
accessible. The TSB believes that the lack of comprehensive in-flight fire fighting procedures,
and coordinated aircraft crew training to use those procedures, constitutes a safety
deficiency. Therefore the TSB made the following recommendation: Appropriate regulatory
authorities review current in-flight fire-fighting standards including procedures, training,
equipment, and accessibility to spaces such as attic areas to ensure that aircraft crews are
prepared to respond immediately, effectively and in a coordinated manner to any in-flight
fire. A00-20 (issued 4 December 2000)”
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Appendix 3
ICAO - Dangerous Goods
The ICAO recommended procedures for responding to lithium battery fires can be found in
Appendix 3. (ICAO DOC 9481 – AN/928 – Emergency Response Guidance for Aircraft
Incidents Involving Dangerous Goods.)
Recommended Procedures in Case of Fire Involving a Portable
Electronic Device
Use standard procedures – obtain and use a fire extinguisher
Standard emergency procedures must be used to deal with any fire. Although Halon has been
shown not to be effective against lithium metal fires, Halon will be effective in fighting the
subsequent fire of surrounding materials, or in fighting a lithium-ion battery fire.
Remove external electrical power from the device if applicable
A battery has a higher likelihood of catching fire through thermal runaway during or
immediately following a charging cycle, although the effects of thermal runaway* may be
delayed for some period of time. By removing external power from the device, it will be
assured that additional energy is not being fed to the battery to promote a fire.
*Note: Thermal runaway is a situation where an increase in temperature changes the
condition in such a way that causes a further increase in temperature, often leading to a
destructive result.
Douse the device with water or other non-flammable liquid to cool cells
and prevent ignition of adjacent cells
If available, a water fire extinguisher should be used to cool the cells in the battery that have
ignited, preventing the spread of heat to adjacent cells. If a water fire extinguisher is not
available, any non-flammable liquid may be used to cool the cells and the device.
Do not move the device
A battery pack involved in a fire has been shown to reignite and emit flames multiple times
as heat is transferred to other cells in the pack. It is preferable to cool the device using water
or other non-flammable liquid. Injuries may occur if the device reignites while the device is
being moved.
Remove power to remaining electrical outlets until the aircraft’s system can be
determined to be free of faults, if the device was previously plugged in
By removing power to the remaining electrical outlets, it can be assured that a malfunctioning
aircraft system does not contribute to additional failures of the passengers PEDs.
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In case of spillage – collect emergency response kit or other useful items
Collect emergency response kit, if provided, or collect for use in dealing with spillage or
leakage:
•
A supply of paper towels, newspapers or other absorbent paper or fabric such
as seat cushion covers, head rest covers, etc;
•
Oven gloves or fire resistant gloves, if available.
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Appendix 4
Case Studies
Catastrophic In-flight Fires
Boeing 707 - Paris, France – 11 July 1973
(Reference: Journal Official de la Republique Francaise – 1976 No: 17 – 6 April 1976
and Cabin Safety Research Technical Group Accident Database, Version 4.3, Issue 16
Accident Reference 19730711A.)
The Boeing 707 was en-route from Rio de Janerio to Paris.
There were 134 passengers and crew on board. There were only 11 survivors.
The problem started with a fire in one of the aft lavatory compartments. Crew members were
unable to contain the fire and smoke and were unable to identify the source of the fire. The
captain reported a malfunction to the engines and requested ATC for an emergency landing at
Orly. The captain also reported “fire on board”.
Smoke migrated into the passenger cabin and into the flight crew compartment. Flight crew
donned oxygen masks and smoke goggles but the amount of black smoke in the flight crew
compartment meant that the flight crew could not see the instruments and therefore the flight
crew compartment were opened and an emergency landing was made with the flight crew
using the open windows to make a crash landing in a field.
It is thought that many passengers died from smoke inhalation whilst the aircraft was in
flight.
The Accident Report stated: “Although the hypothesis of a fire which originated in the left
toilet cannot be excluded, it is more likely that the fire started and developed in the aft right
toilet probably in the washbin unit.”
Since that time many requirements have been introduced to address potential problems with
lavatory compartment fire issues. However, with smoking prohibitions on aircraft now in
place in most countries, and potential non-compliance by passengers with the restrictions, the
possibilities of a lavatory compartment fire continues to be threat to flight safety. Cabin crew
still need to be vigilant and to continue their routine inspections of lavatory compartments
and associated smoke detectors.
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Douglas DC-9 - Cincinnati, USA - 2 June 1983
(Reference: National Transportation Safety Board Report – NTSB/AAR – 86/02 and
Cabin Safety Research Technical Group Accident Database – Accident Reference
19830602A.)
The DC-9 was en-route from Dallas to Toronto, and onwards to Montreal.
There were 46 passengers and crew on board. There were 23 fatalities.
The flight crew heard the circuit breakers ‘popping’ and associated this with the aft lavatory
compartment flush motor. The flight crew did not consider this to be a serious problem. They
attempted to reset the circuit breakers. The cabin crew identified a strong smell and this was
traced to the aft lavatory. A fire extinguisher was discharged into the lavatory compartment
and it was thought that the fire had been extinguished. The first officer donned breathing
equipment and went aft to investigate/fight the fire. The passengers began to smell smoke in
the cabin and the ‘Master Breaker’ alarm went off on the flight deck.
A diversion was made to Cincinnati and soon after touch down the interior of the aircraft
ignited. When the aeroplane stopped, visibility in the cabin was almost non-existent at a
distance of two to three feet above the cabin floor.
The NTSB Accident Report determined that the probable causes of the accident were a fire of
undetermined origin, underestimated severity and misleading information provided to the
captain on the progress of the fire. The NTSB concluded that the air conditioning packs were
turned off some four minutes before the landing at Cincinnati and therefore there was
virtually no fresh air supply into the flight crew compartment and the passenger cabin. The
Accident Report stated: “Propagation – regardless of the ignition source, the physical
evidence showed that there was an area of intense burning in the lower aft outboard corner
of the lowest section of the amenities section, and it also showed that the fire propagated
forward from that point. As the fire moved forward from the amenities section, it also burned
through the lavatory walls allowing smoke, hot gases, and fumes to rise to the air space
between the lavatory shell and the airplane’s outer skin and between the aft pressure
bulkhead and the lavatory’s line walls.”
The time taken to initiate an emergency descent and diversion contributed to the accident.
Had a decision been made by the captain earlier, the aircraft could have landed at Louisville,
and between three to five minutes would have been saved.
The source of the smoke was never identified by the cabin crew or the first officer. The
captain was not advised of the exact location of the fire, nor did he ask for precise location or
extent of the fire. Crew members reporting that the fire was abating misled the captain about
the fire severity and he delayed his decision to declare an emergency and to land.
CAA Paper 2002/01 stated: “The precise source of the fire was never established. However it
propagated between the trim panels and the fuselage. As the aircraft successfully landed,
even a slowing of the propagation of the fire would have allowed all passengers to
successfully evacuate. It is therefore assessed that enhancements to fires in hidden areas
would have resulted in all lives being saved”.
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Boeing 747-200 (Combi) - Indian Ocean (off Mauritius) – 28 November 1987
(Reference: Report of the Board of Inquiry into the Loss of South African Airways
Boeing 747-244B Combi Aircraft “Helderberg” in the Indian Ocean on November 28th
1987.)
The Boeing 747-200 (Combi) was en-route from Taiwan to Johannesburg via Mauritius.
There were 229 passengers and crew on board. There were no survivors.
The captain contacted Mauritius ATC to report a smoke problem and requested permission to
descend. Two minutes later a full emergency was declared and when asked for a position the
captain was uncertain and advised ATC they had lost a lot of electrics. Another two minutes
later the position was reported to be 65 miles from Mauritius. Communication with the
aircraft was lost 20 minutes after initial contact.
The position given by the Captain was not correct and it was 12 hours before floating
wreckage from the aircraft was spotted and in that time had drifted some way from the point
of impact.
Time for the in-flight fire becoming non-survivable was 19 minutes.
The location of the aircraft on the seabed took some time and was eventually found at a depth
of 16,000 feet (5,000 metres). There were 3 separate debris fields. These were 1.5, 2.3 and
2.5 km apart which suggest that the fuselage broke up before impact with the water.
The investigation identified that the seat of the fire was in the forward right hand pallet which
would have been located just behind the bulkhead and ‘G’ net for cargo restraint aft of door
4R. The cargo manifest for that pallet showed that it contained mostly computers in
polystyrene packaging. It is possible that the fire produced gases that accumulated in the
ceiling area of the cargo compartment and that a ‘flash’ fire occurred. Nothing was ever
proven regarding the carriage of undeclared dangerous goods apart from the fact that a major
and catastrophic fire in the main deck cargo compartment caused the loss of the aircraft.
Since the FAA was responsible for the original certification of the Boeing 747 ‘Combi’ it was
their responsibility to review the airworthiness considerations and effectiveness of fire safety
for the aircraft. At that time there were many ‘Combi’ 747’s operating worldwide.
The FAA came to the conclusion that new requirements were needed to address the
possibility of an in-flight fire on ‘Combi’ aircraft. During their review the FAA consulted
widely with manufacturers and operators as well as with the JAA and Transport Canada Civil
Aviation (TCCA). This resulted in the issue of an FAA Airworthiness Directive that would
affect not just the Boeing 747 ‘Combi’ but other large ‘Combi’ aircraft.
The FAA Airworthiness Directive introduced significant new requirements for ‘Combis’ and
some operators found that complying with these new standards was not economically viable.
Note: A ‘Combi’ is an aircraft configured for the carriage of passengers and cargo on the
same deck. On this Boeing 747 the cargo was carried in pallets between Doors 4 and 5 on the
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main deck. The cargo compartment on this aircraft was categorised as Class ‘B’ and relied on
crew intervention to fight an in-flight fire.
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Douglas MD-11 - Nova Scotia, Canada – 2 September 1988
(Reference: Transportation Safety Board of Canada Aviation Investigation Report
Number A98H0003 and Cabin Safety Research Technical Group Accident Database –
Reference 19980902A.)
The MD-11 was en-route from New York to Geneva.
There were 231 passengers and crew on board. There were no survivors.
About 53 minutes after take-off the flight crew detected a smell in the flight deck and their
attention was drawn to an unspecified area above and behind them. Whatever they saw
initially was no longer visible and they agreed that the origin was something to do with the
air conditioning system.
When they had assessed what they had seen was definitely smoke they decided to divert and
were advised by ATC that Halifax would be their nearest aerodrome.
While the flight crew were preparing for the landing in Halifax they were unaware that a fire
was spreading above the ceiling area at the front of the aircraft.
About 13 minutes after the abnormal odour was first detected the FDR began to record a
rapid succession of aircraft systems-related failures. The flight crew then declared an
emergency.
About one minute later the radio communications were lost with the aircraft and the flight
recorders stopped functioning.
Some five minutes later the aircraft crashed into the sea at Peggy’s Cove, Nova Scotia.
The investigation into this accident by the Transportation Safety Board (TSB) of Canada took
more than 4 years. The probable cause of the accident was a combination of faulty wiring and
flammable materials. The TSB report concluded that the aircraft certification standards for
material flammability were inadequate. They also concluded that arcing from electrical
wiring associated with the in-flight entertainment system was the likely cause of fire ignition
and that the circuit breakers on the MD11 were not capable of protection against all types of
arcing events.
The TSB report included the following statements:

In the operating environment at the time, operators did not have policies in place to
ensure that flight crews would be expected to treat all odours and smells as potential
fire threats until proven otherwise.

An effective fire fighting plan shall include procedures that address the optimum
involvement of flight crew and cabin crew to detect, locate, access, assess, and
suppress an in-flight fire in a coherent and coordinated manner.

The cabin crew were trained to locate and extinguish in-flight fires, but their training
was limited to those areas of the aircraft that were accessible. This training would not
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prepare cabin crew members for fire fighting in the attic area or other hidden areas.
Cabin crew were not specifically trained to fight fires in the cockpit or avionic
compartment areas.

There was no integrated in-flight fire fighting plan in place for the accident aircraft,
nor was such a plan required by regulation.

Coordination between the flight crew and the cabin crew was consistent with
company procedures and training.

Crew communications reflected that the situation was not being categorised as an
emergency until six minutes before impact.

No smoke was reported in the cabin by the cabin crew at any time before the CVR
stopped recording.

As a minimum aircraft crews need to be provided with a comprehensive fire fighting
plan that is based on the philosophy that the presence of any unusual odour or smoke
in an aircraft should be considered to be a potential fire threat until proven otherwise.
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Boeing 747-44AF - Dubai, United Arab Emirates – 3 September 2010
(Reference: General Civil Aviation Authority of the United Arab Emirates (GCAA) –
Air Accident Investigation Report – AAIS Case Reference 13/2010 – Uncontained
Cargo Fire Leading to Loss of Control Inflight and Uncontrolled Descent into Terrain)
On 3rd September 2010 Boeing 747-44AF departed Dubai International Airport (DXB) on a
scheduled cargo flight to Cologne in Germany.
Earlier in the day the aircraft had arrived at DBX from Hong Kong with a mixed cargo
including significant consignments of lithium batteries. These lithium battery consignments
remained on board for the sector from DBX to Cologne.
Two flight crew were on board the aircraft.
Twenty minutes into the flight, at approximately 32,000 ft, the flight crew contacted Bahrain
ATC to advise that there was an indication of a fire in the forward main deck cargo
compartment.
The flight crew declared an emergency and a return to DXB was requested.
Additionally the flight crew advised that the flight crew compartment was full of smoke and
that they could not see the radios.
The CVR detailed a pitch control problem that was discussed by flight crew during the first
five minutes of the emergency.
The amount of smoke in the flight crew compartment impaired the ability of the flight crew
to safely operate the aircraft for the duration of the flight back to DBX.
During the descent to DBX, the captain’s oxygen supply ceased to function and resulted in
him leaving his seat and not returning for the remainder of the flight due to incapacitation
involving inhalation of toxic gases. It was confirmed during pathological examination that the
captain lost consciousness due to toxic poisoning.
The first officer became the pilot flying but could not see outside the flight crew
compartment, the primary flight crew displays or the audio control panel in order to return to
the United Arab Emirates (UAE) radio frequencies.
The GCAA Accident Investigation Report states:
“The penetration by smoke and fumes into the cockpit area occurred early into the
emergency. The cockpit environment was overwhelmed by the volume of smoke. There are
several mentions of the cockpit either filling with or being continuously ‘full of smoke’, to the
extent that the inability of the crew to safely operate the aircraft was impaired by the inability
to view their surroundings”. “……the crew could neither view the primary flight displays,
essential communications panels or the view from the cockpit windows.”
As the aircraft approached DBX the flight crew were advised that they were too high and too
fast and that a 360° turn was required. After the aircraft overflew DBX the flight crew were
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advised that an alternative aerodrome at Sharjah International Airport (SHJ) approximately
10 nautical miles away was available.
The flight crew confirmed a heading change and the aircraft reduced speed and entered a
descending right turn south of DBX before radar contact was lost. Loss of control of the
aircraft resulted in an uncontrolled descent into terrain, 9 nautical miles south west of DBX.
There were no survivors.
The final GCAA report included 95 findings and 36 recommendations. The report concluded
that a large fire developed in palletised cargo on the main deck consisting of consignments of
mixed cargo including a significant number of lithium battery types and other combustible
materials. The fire escalated rapidly into a catastrophic uncontained fire.
This accident reinforces the importance of urgent action by the flight crew in making an
emergency descent and diversion to the nearest available aerodrome, and the importance of
maintaining the smoke barrier although the penetration of smoke into the flight crew
compartment on this occasion was not under the control of the flight crew.
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Non-Catastrophic In-flight Fires and Smoke Incidents
Lockheed L-1011 Tristar – 170 miles east of Goose Bay, Canada – 17 March 1992
(Reference: Lois Kyle-Issenman – Transportation Safety Board of Canada – SCSI
International Aircraft Cabin Safety Symposium - Costa Mesa – 1993)
The Lockheed L-1011 Tristar was en-route from Frankfurt to Atlanta.
The aircraft was 170 nautical miles east of Goose Bay when the cabin crew reported a fire
towards the rear left side of the cabin. At the same time a pneumatic duct overheat warning
light illuminated in the flight deck. Shortly after this the cabin crew reported that the fire had
been extinguished. The aircraft diverted to Goose Bay where it landed safely.
The fire started under the rear passenger floor between the side wall of the mid cargo
compartment and the exterior wall of the aircraft. This is known as the ‘cheek’ area and on
the L1011 extends from the wheel well to the aft pressure bulkhead. Flames suddenly entered
the cabin through the return air vent and were reported to be two feet in height above the
cabin floor.
When the fire was detected the cabin crew rapidly established communication with the flight
crew. The cabin crew carried out their procedures quickly and efficiently. The 1st cabin crew
member on the scene determined that the fire was electrical and used a Halon extinguisher.
A 2nd cabin crew member used a water extinguisher on burning clothing. A 3rd cabin crew
member contacted the flight crew and communication with the flight crew was maintained
throughout the incident. Back-up fire extinguishers were relocated from the flight deck just in
case they were required.
It took three minutes to extinguish the fire using three Halon and one water fire extinguishers.
Passengers from the area of the fire were relocated to other seats in the passenger
compartment.
One of the flight crew came into the cabin to assess the damage and to confirm that the fire
had been extinguished, and a PA was made by the flight crew to reassure passengers.
Although there was considerable burn damage it was localised due to the fact that the fire was
extinguished before it could spread.
The most probable cause of the fire was electrical arcing and an accumulation of dust and lint
in the area.
The cabin crew fought the fire rapidly and effectively and the Halon extinguished the fire
very effectively.
The cabin crew displayed excellent decision making, crew coordination, communication and
leadership.
App 4-9
www.aerosociety.com
One of the main messages from this potentially catastrophic occurrence confirms that the
importance of effective procedures and that the importance of effective training should never
be underestimated.
App 4-10
www.aerosociety.com
Airbus A340 – 120 miles north of Lusaka, Zambia – 5 December 1998
(Reference: AAIB Bulletin No: 8/99
Ref: EW/C98/12/1)
The A340 was en-route from London to Johannesburg. There were 273 passengers and crew
on board.
Nine hours into the flight, with some of the cabin crew taking rest in the lower lobe crew rest
area, a passenger notified the cabin crew in the aft galley that there was a fire in the cabin.
The cabin crew identified that there was a fire in a central overhead bin towards the back of
the cabin. On reaching the location the cabin crew member attempted to discharge the Halon
extinguisher but was unable to exert enough pressure on the extinguisher handle to break the
seal in order to initiate operation. A passenger took the extinguisher and discharged its
content into the overhead bin and also discharged the contents of a second extinguisher which
had been handed to him. The fire was extinguished but there was a considerable amount of
smoke and passengers in the area were advised to keep their heads down.
The captain was advised of the situation and the relief pilot was sent to the cabin to assist and
evaluate the situation. It was determined that since the fire was extinguished the flight would
continue to its destination.
All cabin crew received initial practical training in the use of fire extinguishers and additional
practical training every three years, so why was the cabin crew member unable to initiate
discharge of the fire extinguisher?
The actual use of ‘live’ fire extinguishers during crew training is prohibited under the terms
of the Montreal Protocol, so most crew fire training is achieved with Halon extinguishers
filled with water. As a result the fire extinguishers used in training did not fully replicate the
extinguishers carried on board the aircraft. This was especially true of the integral brass seal
that needed to be broken on this type of extinguisher when the operating handle is pressed.
The force of breaking this seal on an ‘operational’ fire extinguisher was considerably greater
than the force needed to activate discharge on fire extinguishers used in training.
App 4-11
www.aerosociety.com
Cessna 550 Citation – Manchester, England – 21 April 2003
Ref: EW/G2003/04/19)
The Cessna 550 Citation was operating a positioning sector from Edinburgh to Manchester
Airport with two flight crew on board and no passengers.
On the approach and descent into Manchester the flight crew became aware of a smell of
burning electrical insulation and although there was no smoke in the flight crew compartment
at this stage, the cabin was observed to be full of smoke.
The captain instructed the co-pilot to don his oxygen mask and at the same time initiated a
MAYDAY call to air traffic control. At this time smoke began to enter the flight crew
compartment causing the captain breathing difficulties. Having made the MAYDAY
transmission the captain donned oxygen and as he did so smoke was beginning to obscure the
instrument panel and forward vision from the flight crew compartment.
With no evident malfunction in the flight crew compartment the captain initiated the SMOKE
REMOVAL emergency drill from memory. The captain decided not to carry out any
subsequent emergency drills as he considered that the preparation for the approach and
landing at Manchester was the priority.
During the visual final approach the concentration of smoke in the flight crew compartment
increased again, although forward vision was not restricted further. The flight crew landed
the aircraft normally and stopped it on the runway before shutting down the engines,
removing all electrical power and evacuating via the forward main exit.
The captain sustained a sore throat and chest due to inhalation of smoke whilst making the
MAYDAY transmission.
Subsequent examination of the aircraft and aircraft parts by the operator and by the AAIB
established that the internal condition of the ‘cockpit’ defog fan was responsible for
considerable smoke being drawn from the fan into the cabin air-flow.
The operator’s emergency procedure for a smoke event was contained in the Operations
Manual issued to each captain and included in the flight crew compartment emergency
checklist. The flight crew would normally be required to conduct either the ELECTRICAL
FIRE OR SMOKE drill or the ENVIRONMENTAL SMOKE OR ODOUR, drill depending
on the perceived source of the smoke.
The procedure also directs the flight crew to declare a MAYDAY and to “LAND AS SOON
AS POSSIBLE”. It then advises the flight crew to carry out SMOKE REMOVAL if this is
warranted. The Operations Manual also states: “The pilot-in-command shall, in an emergency
situation that requires immediate decision and action, take any action he considers necessary
under the circumstances. In such cases he may deviate from rules, operational procedures,
and methods in the interest of safety.
The AAIB report also stated that the captain’s decision not to complete relevant emergency
procedures was influenced by the time available and the need to concentrate on the approach
and landing at Manchester.
App 4-12
www.aerosociety.com
In effect, the captain chose to action what he considered to be the most important part of the
procedure, i.e. “Land as soon as possible”
Note: The flight crew compartment is separated from the passenger cabin by a curtain and not
by a flight crew compartment door.
App 4-13
www.aerosociety.com
Bombardier DHC-8 - Leeds, England – 4 August 2005
Ref: EW/C2005/08/10)
The DHC-8 was en-route from Birmingham to Edinburgh.
There were 60 passengers and crew on board.
During the flight an oily smell was noticed in the flight deck followed by a build-up of smoke
in the flight deck and the cabin. The flight crew declared an emergency and ATC suggested
Leeds as the most suitable aerodrome for a diversion.
The cabin crew donned PBE and prepared the cabin for an emergency landing. The cabin
crew found that the smoke level in the cabin was getting thicker and that they could no longer
see the length of the cabin. After landing at Leeds an emergency evacuation was conducted
without any injury.
The cause of the smoke was later identified as a crack in the compressor support member of
the No. 2 engine.
Due to the high flight crew work-load during the emergency, the flight crew were prevented
in communicating with the cabin crew for some time. This caused concern to the cabin crew
as to the state of the flight crew. Additionally, the cabin crew reported that the PBE severely
hindered communication with passengers. Because of this one of the cabin crew decided to
remove their PBE before landing.
Checks made during the investigation confirmed that verbal communication whilst wearing
PBE was difficult even when in close proximity to another person. The operator’s training
criteria required cabin crew to practice donning PBE once a year and wearing PBE in a
smoke-filled environment once every three years. The accident investigators concluded that
this training had not fully prepared the cabin crew for the extent of the associated difficulties,
raising questions as to effectiveness of their training.
The AAIB made the following safety recommendations:
“It is recommended that for all large aircraft operating for the purpose of public transport,
the UK CAA and the EASA should take such steps, procedural or technical, as are necessary
to improve the reliability and availability of communication between flight and cabin crews,
including the reliability of communications equipment and associated power supplies in both
normal and emergency configurations.”
“It is recommended that the UK CAA and EASA review the current training requirements for
cabin crew in the use of smoke hoods to mitigate the communications difficulties which may
be encountered and to improve the ability of all crew members to communicate while
wearing smoke hoods.”
App 4-14
www.aerosociety.com

Smoke, Fire and Fumes in Transport Aircraft, Part 2

Transcription

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